What are the responsibilities and job description for the Clinical Appeals Reviewer - RN License Required position at Global Force USA?
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
Salary : $42
