Clinical Review Clinician - Appeals
You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards Communicates with members, providers, facilities, and other departments regarding appeals requests Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards Works with leadership to increase the consistency, efficiency, and appropriateness of responses of reputed company appeals requests Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices Performs other duties as assigned Complies with reputed company policies and standards Registered Nurse with behavioral health and Medicare appeals experience preferred. Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelors degree in Nursing and 2 4 years of reputed company experience. Knowledge of NCQA, Medicare and reputed company regulations preferred. Knowledge of utilization management processes preferred. License/Certification: LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Psychologist required Pay Range: $26.50 - $47.59 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law. Total compensation may also include additional forms of incentives. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without regard to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act Apply Job!