About the Role:

• The Clinical Appeals Specialist completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions.
• The Clinical Appeals Specialist utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and Government Programs lines of business in order to formulate a professional response to the appeal request.

Responsibilities: -

• Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stakeholders, and any other initiators.
• Organizes the appeal case for physician review by compiling clinical, contractual, medical policy and claims information along with corporate and appellant correspondence.
• Formulates recommendations for disposition.
• Investigates, interprets, analyzes, and prioritizes appeal requests using nursing expert knowledge and all available clinical information for both medical and behavioral health conditions, as well as medical policies, to determine if the adverse coverage and adverse decisions are appropriate.
• Maintains a ready command of a continuously expanding knowledge base of current medical practices and procedures, including current medical, mental health and substance abuse/addiction procedural terminology, surgical procedures, dental procedures, diagnostic entities and their complications.

Education Qualification: -

• High School Diploma
• 2 years medical-surgical or similar clinical experience OR 3 years experience in a mental health, psychiatric setting.

Required Skills: -

• Knowledge and understanding of medical terminology.
• Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.

Preferred:

• 2 years experience in Medical Review, Utilization Management, or Case Management at a Managed Care organization or hospital.
• Preferred: BSN/MSN Degree.