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AmeriHealth Caritas · 1 week ago

Clinical Appeals Reviewer

United States

Full-time

Remote

Mid Level

3+ years exp

AmeriHealth 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

Registered Nurse (RN) licensureInterQual criteria knowledgeClinical experienceDiagnosis procedure codesMS Office proficiencyTask managementVerbal communicationWritten communicationCritical thinkingPresentation skills

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