Demo

Clinical Appeals Reviewer

Della Infotech, Inc.
Newtown, PA Full Time
POSTED ON 4/1/2025
AVAILABLE BEFORE 4/30/2025

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

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

Schedule Notes : Monday-Friday 8 : 30am-5pm EST

Required Skills : CMS,OPERATIONS,REGISTERED NURSE,MEDICAL RECORDS,PACKAGING,

Additional Skills : CONTENT MANAGEMENT SYSTEM,

Hours Per Day : 8.00

Hours Per Week : 40.00

Languages : English( Speak, Read, Write )

Department : AMHSS_1000_431 : Clinical Appeals Medicare

Job Category : NonClinical - Admin / Claims / CSR / Tech

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