Summary:
The Clinical Appeals Reviewer plays a key role in processing appeals and grievances, ensuring compliance with regulatory timeframes and standards. This role involves clinical expertise, case investigation, and communication with providers, members, and regulatory entities to support accurate medical determinations.

Position Info:

• Title: Clinical Appeals Reviewer
• Client: AmeriHealth Caritas
• Duration: 3 Months
• Location: 3875 West Chester Pike Newtown Square PA 19073
• Work Mode: Remote

Responsibilities:

• Review appeals and grievances to ensure compliance with regulatory milestones.
• Obtain and analyze medical records, summarizing case details for determination.
• Communicate with providers and members to gather necessary clinical information.
• Apply clinical expertise to evaluate medical necessity and case classifications.
• Prepare thorough case summaries for Medical Director review and assist in final determinations.
• Draft decision letters in adherence to regulatory requirements and compliance timeframes.
• Stay updated with CMS policies, procedures, and standards.

Skills/Qualifications:

• 3+ years of experience in a related clinical setting.
• Registered Nurse graduate from an accredited program.
• Current, unrestricted Registered Nurse (RN) license.
• Proficiency in CMS operations and regulatory compliance.
• Experience with medical records analysis and case packaging.
• Familiarity with Interqual criteria for case reviews.
• Strong understanding of federal, state, and CMS regulations related to appeals and grievances