What are the responsibilities and job description for the Clinical Appeals Reviewer position at TalentBurst, Inc.?
Clinical Appeals Reviewer
Newtown Square, PA / Remote
13 weeks
3 or more years' experience in a related clinical setting
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.
