Clinical Appeals Reviewer - Integrated Resources, Inc
Newtown Square, PA
About the Job
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.
Education:
Registered Nurse graduated from an accredited program. Current unrestricted Registered Nurse license.
Languages:
English( Speak, Read, Write )
Skills:
3 or more years experience in a related clinical setting
City: Newtown Square
Schedule:
Start Date: 01/20/2025
End Date: 04/30/2025
Schedule Notes: Monday-Friday 8:30am-5pm EST
Hours Per Week: 40.00
Hours Per Day: 8.00
Days Per Week: 5.00
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.
Education:
Registered Nurse graduated from an accredited program. Current unrestricted Registered Nurse license.
Languages:
English( Speak, Read, Write )
Skills:
3 or more years experience in a related clinical setting
City: Newtown Square
Schedule:
Start Date: 01/20/2025
End Date: 04/30/2025
Schedule Notes: Monday-Friday 8:30am-5pm EST
Hours Per Week: 40.00
Hours Per Day: 8.00
Days Per Week: 5.00
Source : Integrated Resources, Inc