Clinical Appeals Reviewer Job Description

Clinical Appeals Reviewer Job Description

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164 votes for Clinical Appeals Reviewer
Clinical appeals reviewer provides education to providers on the appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes.

Clinical Appeals Reviewer Duties & Responsibilities

To write an effective clinical appeals reviewer job description, begin by listing detailed duties, responsibilities and expectations. We have included clinical appeals reviewer job description templates that you can modify and use.

Sample responsibilities for this position include:

Ensuring all World Trade Center Health Program claims are processed in a timely manner with acceptable accuracy
Secondary review of claims approval tasks within MedNet
Be familiar with business / industry concepts and terminology as pertains to appeals, grievances and claims processing
Solves complex problems on own
Produces approval & denial letters on behalf of the Medical Director for submission to member, provider or hospital
Ensure quality customer service, maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals processing
Creates training materials and acts as a team trainer on new and revised policies and criteria
Acts as a subject matter expert (SME) within the department
Performs department and clinical audits at the request of management
Review and reconsider determinations regarding whether cases should be reopened after determination has been made

Clinical Appeals Reviewer Qualifications

Qualifications for a job description may include education, certification, and experience.

Education for Clinical Appeals Reviewer

Typically a job would require a certain level of education.

Employers hiring for the clinical appeals reviewer job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Associates, Health

Skills for Clinical Appeals Reviewer

Desired skills for clinical appeals reviewer include:

Community
State and federal laws and resources
Experience with CPT and ICD-9 coding
Medical terminology
Claims
HMO and /
Medical Terminology and ICD-10 / CPT coding
Medicare / Medicaid guidelines
NJ Auto Regulations

Desired experience for clinical appeals reviewer includes:

Must be able to use various software
Minimum of 3 years of nursing experience, in related clinical setting, preferably critical care
Experience with Utilization Review and/or Prior Authorization
Familiar with Interqual Criterion
Knowledge of MS Office including Word, Excel, and Outlook
Ability to travel to Harrisburg, Scranton, and Clearfield, PA

Clinical Appeals Reviewer Examples

1

Clinical Appeals Reviewer Job Description

Job Description Example
Our growing company is hiring for a clinical appeals reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical appeals reviewer
  • Offers quality improvement suggestions on project protocols and processes
  • Work with Review Supervisor/Sr
  • Facilitate the code request process with LHI and the World Trade Center Health Program
  • Maintenance of the World Trade Center Health Program code book within MedNet
  • Submit service code requests for newly added ICD / CPT codes to the contract
  • Provide client, member and / or provider support to drive resolution of issues that may arise
  • Develop and maintain productive and positing contacts and follow - up with clients, members and / or providers either via phone, email, mail or fax
  • Provide consulting / education to clients based on issue/trends as it pertains the assigned appeal, grievance or claim
  • Resolve member service inquiries as it relates to the member and / or provider
  • Triage calls, email, fax or mail received to determine resolution type and transfer to the appropriate department, where applicable
Qualifications for clinical appeals reviewer
  • Must live in or around Atlanta, GA, Chicago, IL, Philadelphia, PA, or St
  • Must live in or near San Francisco, CA or Maryland Heights, MO or Atlanta, GA
  • Masters- level Behavioral Health Professional (LPC or LCSW) to practice at the independent practice level with current license in good standing in state of operations
  • Current DE RN licensure
  • Required minimum of 3 years of nursing experience, in related clinical setting, preferably critical care
  • Required experience with Utilization Review and/or Prior Authorization
2

Clinical Appeals Reviewer Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of clinical appeals reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical appeals reviewer
  • Receive, process, refax or re - route letters to providers and facilities, where applicable
  • Ensure accurate documentation of all forms of communications received by clients, members and / or providers
  • Research complex issues across multiple databases and work with support resources to resolve inquiry independently
  • Ensure the correct letter template is utilized when selecting the correct attachments and/or enclosure(s)
  • Fully complete system templates, as required and in accordance with internal processes
  • Send completed written notification as indicated under applicable department policies
  • Work with team to solve complex problems, where applicable
  • Work with under supervision / guidance on high level tasks with strict deadlines
  • Holds to the philosophy and standards of quality as outlined by Optum
  • Handle pharmacy appeals cases that require clinical review includes verifying the need for clinical review
Qualifications for clinical appeals reviewer
  • Must live in or near St
  • Required experience with preparing clinical appeals, denials or adverse determination
  • Required - A High School or GED is required, a Bachelor's Degree in a related area is preferred
  • Required - 4+ years of experience in a clinical setting with general nursing exposure in UM to include pre-authorization, utilization review, concurrent review, discharge planning, CM w/review, and/or skilled nursing facility reviews
  • 4+ years experience in managed care preferred
  • Preferred 1+ year of experience in an acute care clinical setting (Medical and/or Behavioral Health)
3

Clinical Appeals Reviewer Job Description

Job Description Example
Our company is growing rapidly and is looking for a clinical appeals reviewer. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for clinical appeals reviewer
  • Verifying Member coverage and clinical programs that apply
  • Routing cases to the correct Pharmacist queue or Medical Directors (when required)
  • Assure appeals are resolved within regulatory timeframes
  • Assure grievances / complaints and DOI issues are handled within regulatory timeframes
  • Utilizes MCG Criteria, CMS Guidelines, medical and administrative policies to evaluate medical necessity of requested service, applying sound clinical judgement
  • Reviews clinical cases and formulates responses for Grievance and Appeals
  • Prepares and presents clinical detail to the Medical Director for final case determination in accordance with regulation and department policy
  • Ensures internal and regulatory time frames are met
  • Utilizes the member’s contract to determine coverage eligibility
  • Determine if appeal is clinical or administrative
Qualifications for clinical appeals reviewer
  • Must live in St
  • Must Live near Schaumburg, IL
  • Preferred 2+ years of experience in Managed care experience
  • Required Intermediate Healthcare Management Systems (Generic) Ability to use proprietary healthcare management system
  • Preferred A Bachelor's Degree in a related area
  • Required 1+ year of experience in an acute care setting (Medical)
4

Clinical Appeals Reviewer Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of clinical appeals reviewer. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for clinical appeals reviewer
  • Compile IRO packets
  • Meet or exceed all performance standards established for this position
  • Provide written clinical rationales for CA Workers Compensation cases
  • Perform special projects as assigned such as legal research, general medical research
  • Work on special projects to improve CA IMR project or other special projects as assigned
  • Plan, prioritize, organize and complete work to meet established and required timeframes
  • Demonstrates a depth and breadth of knowledge / skills in own area which could include but not limited to
  • Research appeal or grievance requests in multiple computer applications to obtain information that may impact review
  • Initiate and maintain appeal or grievance review documentation in appropriate tracking systems (e.g., Linx, iCUE, Cirrus, ISET, CSP Facets, ETS)
  • Create and utilize tracking databases in Excel to document additional information as necessary
Qualifications for clinical appeals reviewer
  • Intermediate Other Ability to build high morale and obtain group commitments to goals and objectives
  • Intermediate Other Capability of working extra time and/or be “on-call” at request of management
  • Intermediate Other IRR Appeals Reviewer Test - >85% passing score
  • Intermediate Other Ability to consistently meet the established production goals (over 30 files/week)
  • Ability to review multiple type of appeal files (member/provider, retro/pre-service, etc)
  • Ability to build high morale and obtain group commitments to goals and objectives
5

Clinical Appeals Reviewer Job Description

Job Description Example
Our growing company is searching for experienced candidates for the position of clinical appeals reviewer. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for clinical appeals reviewer
  • Ensure all records, data, and documentation are entered to close cases
  • Upload medical decisions and documents related to appeals or grievances into record repositoryUpdate appeals or grievance tracking system
  • Review benefit requirements and determine applicability to an appeal or grievance
  • Review appeal denial reason to determine if a case requires clinical intervention of nurse or medical director
  • Work with interdisciplinary team to make determinations as appropriate
  • Make a supported determination for the appeal or grievance (e.g., EOC/COC/SPD supported, review of Policies and Procedures, Regulatory adherence, compliance with turnaround times)
  • Effectuate overturn determinations
  • Monitor and respond to electronic communications timely and/or manage communications in a virtual work environment
  • Acts as a facilitator / key team member on project spanning more than own function as applicable
  • This position is full-time (40 hours/week) Monday- Friday
Qualifications for clinical appeals reviewer
  • IRR Appeals Reviewer Test - >85% passing score
  • Ability to consistently meet the established production goals (over 30 files/week)
  • Required - Proficiency working in Microsoft Word, Excel and Outlook
  • Required - Experience working with a Healthcare Management Systems
  • Some College credits preferred or higher
  • Current, unrestricted PA Registered Nurse license

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