What are the responsibilities and job description for the Clinical Review Specialist - Healthcare Appeals position at Experis?
About the Role
Experis, a global leader in workforce solutions, is seeking an experienced Clinical Review Specialist to join our team. As a key member of our clinical review department, you will play a vital role in supporting the appeals team and ensuring that services meet medical necessity guidelines.
Key Responsibilities
- Conduct thorough clinical reviews of appeal requests, including pre-pay and post-payment review appeals, to determine if requested services meet medical necessity guidelines.
- Provide detailed benefit analysis to support clinical review decisions.
- Document decisions within mandated timeframes and in compliance with applicable regulations or standards.
- Perform research of service appeals based on clinical documentation, contractual requirements, and policies.
- Collaborate with the appeals team to identify quality of care issues and develop strategies for improvement.
Requirements
- Associate Degree in Nursing or Graduate of an Accredited School of Nursing.
- 2 years clinical experience plus 1 year in utilization/medical review, quality assurance, or home health.
- An active, unrestricted RN license from the United States and in the state of hire.
- Strong clinical experience including home health, rehabilitation, or broad medical surgical experience.
- Working knowledge of managed care and various forms of healthcare delivery systems.
About Experis
We are a leading global workforce solutions company, helping organizations transform in a fast-changing world of work by sourcing, assessing, developing, and managing the talent that enables them to win. Our expert family of brands creates substantial value for candidates and clients across more than 75 countries and territories and has done so for over 70 years.
What We Offer
- The opportunity to work in a dynamic and supportive environment.
- A collaborative team atmosphere.
- Potential for remote work after an initial onsite period.
- Meaningful work that impacts patient care and quality.
