What are the responsibilities and job description for the Clinical Appeal Reviewer position at RX2 Solutions?
TITLE: Clinical Appeals Reviewer
TYPE: Contract
LOCATION: Newtown Square, PA
ONSITE/REMOTE/HYBRID: Onsite
START DATE: January 2025
SHIFT: Monday – Friday, 8:30 am – 5 pm
We are looking for a Clinical Appeals Reviewer. The Clinical Appeals Reviewer is responsible for managing the processing of appeals and grievances, ensuring compliance with all regulatory milestones. This role reports to the Supervisor of Appeals and Grievances.
MAIN RESPONSIBILITIES
- Engage with appellants or their representatives to gather and review medical records, compiling all relevant information into a case for evaluation.
- Communicate directly with healthcare providers to obtain necessary clinical details, and support members or their advocates in clarifying the purpose of the appeal or grievance.
- Provide clinical insight throughout the review process and make determinations regarding medical necessity for case classifications when required. This position plays a vital role in maintaining regulatory and compliance standards during the evaluation of appeals and grievances.
- Conduct comprehensive investigations for each case and prepare a detailed Case Summary for review by the Medical Director.
- Receive appeals or grievance cases before assignment to a Medical Director for a formal Medical Determination.
- Review final determinations and draft decision letters that include all mandatory information as specified by regulatory guidelines, ensuring they are dispatched within compliance timeframes.
- Utilize Interqual criteria and apply it effectively in the review of appeals and grievances.
- Stay updated on department policies, CMS regulations, and other related guidelines.
- Ensure adherence to federal, state, and local laws, as well as regulatory requirements related to appeal and grievance operations.
QUALIFICATIONS
- Must be a Registered Nurse graduated from an accredited program and possess a current, unrestricted Registered Nurse license.
- Minimum of 3 years in a relevant clinical environment (required).
- Knowledge of CMS regulations.
- Familiarity with operations management.
- Proficient in managing medical records and packaging information.
- Familiarity with Content Management Systems is preferred.
EOE STATEMENT
We are an equal opportunity employer. We do not discriminate or allow discrimination on the basis of race, color, religion, creed, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law.
Job Type: Contract
Schedule:
- Day shift
- Monday to Friday
Work Location: In person
