Clinical Appeals ReviewerDuties: The Clinical Appeals Reviewer reports to the Supervisor, Appeals and Grievances and is responsible for processing appeals and grievances ensuring all milestones are within compliance.• Outreaches to the appellant or their representative and is responsible for obtaining and reviewing medical records and packaging all pertinent information into a case for a determination.• Directly interacts with providers to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or grievance.• Throughout the performance of their duties, the Clinical Appeals Reviewer provides clinical expertise and may make determination of medical necessity for case classifications when necessary and provides a front-line regulatory/compliance function in their evaluation of appeals and grievances.• Completes a thorough investigation on all cases and providing a detailed Case Summary for the Medical Directors review.• Receives an appeal or grievance case, prior to assigning to a Medical Director for a Medical Determination.• Responsible for reviewing the final determination and creating the decision letter which must contain required information as dictated by regulatory entities and must be mailed on or before compliance timeframes.• Utilizes Interqual criteria and understand how to apply it to Appeals and Grievances reviews.• Stays current with department and CMS policies and procedures.• Maintains familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. CMS standards) relative to appeal and grievance operations.Skills: 3 or more years' experience in a related clinical settingEducation: Registered Nurse graduated from an accredited program. Current unrestricted Registered Nurse license.Skills and Experience:Required Skills:CMSOPERATIONSREGISTERED NURSEMEDICAL RECORDSPACKAGINGAdditional Skills:CONTENT MANAGEMENT SYSTEMLanguages:English Read Write SpeakNotes:RemoteMonday-Friday 8:30am-5pm ESTVIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
(Please ensure email matches your resume email)
(document types allowed: doc/docx/rtf/pdf/txt) (max 2MB)
By submitting this form, you are consenting to the VIVA team contacting you via Phone/Email