Clinical Review and Appeals Specialist




The Clinical Review and Appeals Specialist will play a crucial part in collecting, reviewing, and summarizing clinical information, driving effective clinical decisions in a fast-paced environment. Your responsibilities will include ensuring compliance with relevant processes and procedures and conducting medical reviews of insurance appeals.


  • Collect and review clinical information to facilitate medical reviews of insurance appeals.
  • Analyze and interpret medical records and compose clinical appeals to insurance companies.
  • Compose appeals to dispute insurance adverse determinations related to medical necessity.
  • Construct expedited appeals, in-house concurrent appeals, and 1st and 2nd-level retrospective appeals using clinical rationale.
  • Manage assigned workload of accounts to ensure timely submission of appeals following payer timeframes.
  • Review orders and services, including add-on disciplines, per the clinician’s initial client assessment.
  • Ensure the accuracy and legal compliance of orders by the clinician.
  • Review client medication profiles and schedules.
  • Function as a resource for internal staff and clinicians.
  • Receive and respond to calls/notifications regarding client charts.
  • Document information regarding calls/notifications into the Coordination Notes and update personnel as needed to ensure proper coordination of care.
  • Review the utilization of services based on the documentation provided by the clinical team.
  • Complete and submit all required documentation within specified company requirements.


  • Clinical background with active and unrestricted licensure to practice as an LPN or RN in your state(s) of practice.
  • A minimum of two (2) years of nursing experience.
  • Experience in writing clinical appeals.
  • Ability to develop effective working relationships with the facility and payers.
  • Effective written and verbal communication skills.
  • Strong analytical, organizational, multitasking, and time management skills.
  • Attention to detail.
  • Knowledge of guidelines governing infusion facilities.
  • Knowledgeable about clinical best practices and the ability to make appropriate judgments.
  • Ability to prioritize and organize work efficiently and timely.
  • Ability to create positive impressions and communicate with a variety of people.
  • Maintain effective communication with patients, families, physicians, and co-workers.
  • Ability to professionally handle confidential information according to HIPAA regulations.


  • Managed Care experience.
Scroll to Top