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.
DUTIES AND RESPONSIBILITIES
- 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.