This is a fully remote position, open to applicants in New Mexico.

📋 Description

• Leverages clinical expertise to assess insurance appeals and both prospective and retrospective claims.

• Evaluates all medical records and responds to each inquiry from the client using client-specific standards or other nationally recognized evidence-based guidelines.

• Ensures that the rationale for decisions is articulated clearly, concisely, and includes sufficient supporting documentation to justify the conclusion.

• Identifies, evaluates, and applies current criteria and resources such as national, state, and professional association guidelines, as well as peer-reviewed literature, to support informed and objective decision-making; avoids relying on case studies, cohorts, and similar sources due to their limited sample sizes.

• Provides copies of any criteria used during a review along with the report promptly.

• Returns cases by the specified due date and time.

• Conducts phone calls as required by state regulations and/or client specifications.

• Maintains appropriate credentialing, state licenses, and any additional certifications or requirements necessary to fulfill the role.

• Participates in all necessary orientation and training sessions.

• Performs additional duties as assigned, including addressing quality assurance concerns, complaints, regulatory matters, depositions, court appearances, or audits.