Job Description

Name: Clinical Appeals Reviewer

Type: Staffing

Status: Pending

Client: AmeriHealth Caritas Services

Start: 01/20/2025

End: 04/30/2025

Description:

Reason: New Position

Department: Clinical Appeals Medicare

Job Category: NonClinical - Admin/Claims/CSR/Tech Job Title: Clinical Appeals Reviewer

Duties: The Clinical Appeals Reviewer reports to the Supervisor, Appeals and Grievances and is responsible for processing appeals and grievances ensuring all milestones are within compliance. 

• Outreaches to the appellant or their representative and is responsible for obtaining and reviewing medical records and packaging all pertinent information into a case for a determination. 
• Directly interacts with providers to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or grievance. 
• Throughout the performance of their duties, the Clinical Appeals Reviewer provides clinical expertise and may make determination of medical necessity for case classifications when necessary and provides a front-line regulatory/compliance function in their evaluation of appeals and grievances. 
• Completes a thorough investigation on all cases and providing a detailed Case Summary for the Medical Directors review.
• Receives an appeal or grievance case, prior to assigning to a Medical Director for a Medical Determination.
• Responsible for reviewing the final determination and creating the decision letter which must contain required information as dictated by regulatory entities and must be mailed on or before compliance timeframes.
• Utilizes Interqual criteria and understand how to apply it to Appeals and Grievances reviews.
• Stays current with department and CMS policies and procedures.
• Maintains familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. CMS standards) relative to appeal and grievance operations.

Skills: 3 or more years' experience in a related clinical setting

Keywords:

Education: Registered Nurse graduated from an accredited program. Current unrestricted Registered Nurse license.

Skills and Experience:

Required Skills: 

• CMS
• OPERATIONS
• REGISTERED NURSE
• MEDICAL RECORDS
• PACKAGING

Additional Skills:

CONTENT MANAGEMENT SYSTEM

Languages:

• English
• Read
• Write
• Speak

Patents: No

Publications: No

Veteran Status: No

# of Positions: 1

Location:

Newtown Square, PA

3875 West Chester Pike,

Schedule:

Start Date: 01/20/2025

Estimated End Date: 04/30/2025

Hours Per Week: 40.00

Hours Per Day: 8.00

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