Clinical Review Clinician - Appeals

Position Summary: Perform clinical reviews for pre-service authorization denials and retrospective claim denials to determine if members can/did receive medically necessary services.

Background & Context:

• Shared Services Medicare Appeals department located within EBOS.
• We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers.
  
  Key Responsibilities:
• Staff will work when there are members of the supervisor/leadership on.
• Cases are assigned in round robin fashion for staff to review and work.
• Nurses review case files, add, update or edit authorizations.
• Work closely with the MD team to make final decisions on cases.
• The clinical team works closely with their supervisors and senior clinicians on the team for support.
• Team does have group chats on Teams for routine questions.
• Team works closely together along with the coordinator team who owns end to end process on cases.
  
  Qualification & Experience:
  
  
  
  
  
  

  Candidate Requirements
  Education/Certification	Required: Associate in nursing, Bachelor's in nursing or higher.	Preferred:
  Licensure	Required: RN, LPN	Preferred: LVN
  Years of experience required Disqualifiers Best vs. average Performance indicators	Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals Nice to haves: Medicare Appeals Experience Disqualifiers: Not having a valid/active RN/LPN license Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases Best vs. average: Productivity expectations are set based on platform.
  Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection	1	Utilization Management or Appeals review background (1 plus year)
  2	Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)
  3	Retrospective claims clinical reviews (1 plus year)