AmeriHealth Caritas · 1 week ago
Clinical Appeals Reviewer
United States
Full-time
Remote
Mid Level
3+ years expAmeriHealth Caritas is a mission-driven organization dedicated to providing healthcare solutions. The Clinical Appeals Reviewer is responsible for processing appeals, ensuring compliance with regulatory requirements, and engaging with appellants and providers to gather necessary clinical information for case determinations.
Health CareInformation Technology
Responsibilities
Process appeals, ensuring compliance with all regulatory milestones
Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors
Outreach to appellants or their representatives to obtain and review medical records
Package pertinent information into a case for determination
Interact with providers to obtain additional clinical information
Engage with members or their advocates to understand the full intent of the appeal
Provide clinical expertise and determine medical necessity for case classifications when necessary
Perform front-line regulatory/compliance functions in the evaluation of appeals
Review appeal cases and ensure the Medical Director makes timely decisions
Review final determinations and create decision letters containing required information as regulatory entities dictate
Present cases to committees when necessary
Utilize InterQual criteria and apply them to appeals reviews
Stay current with the department and AmeriHealth Caritas policies and procedures
Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations
Qualification
Required
Bachelor's degree (BSN) required
3 or more years of experience in a related clinical setting and working with diagnosis procedure codes
Working knowledge of InterQual criteria
Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook
Familiarity with the appeals process, preferably within a managed care organization
Current and unrestricted Registered Nurse (RN) licensure or compact state licensure
Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-priority tasks within designated timeframes
Benefits
Flexible work solutions include remote options
Hybrid work schedules
Competitive pay
Paid time off, including holidays and volunteer events
Health insurance coverage for you and your dependents on Day 1
401(k)
Tuition reimbursement
And more.
Company
AmeriHealth Caritas
AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Kathleen Giblin
SVP Clinical Operations
Ash Hanson
Executive Vice President & Chief Human Resources Officer
Recent News
2025-11-06
The Philadelphia Inquirer
2025-10-02
2025-10-01
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