Title: Clinical Review Clinician - Appeals Location: Remote Duration: 6 Months with potential to extend or convert 8-5 EST or CST hours Position Summary: Perform clinical reviews for pre-service authorization denials and retrospective claim denials to determine if members can/did receive medically necessary services. Background & Context: Shared Services Medicare Appeals department located within EBOS. We are a team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers. Key Responsibilities: Staff will work when there are members of the supervisor/leadership on. Cases are assigned in round robin fashion for staff to review and work. Nurses review case files, add, update or edit authorizations. Work closely with the MD team to make final decisions on cases. The clinical team works closely with their supervisors and senior clinicians on the team for support. Team does have group chats on Teams for routine questions. Team works closely together along with the coordinator team who owns end to end process on cases. Qualification & Experience: Candidate Requirements Education/Certification Required: Associate in nursing, Bachelor’s in nursing or higher. Preferred: Licensure Required: RN, LPN Preferred: LVN Years of experience required Disqualifiers Best vs. average Performance indicators Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals Nice to haves: Medicare Appeals Experience Disqualifiers: Not having a valid/active RN/LPN license Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases Best vs. average: Productivity expectations are set based on platform. Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection 1 Utilization Management or Appeals review background (1 plus year) 2 Medicare NCD/LCD and InterQual/Milliman Software (1 plus year) 3 Retrospective claims clinical reviews (1 plus year) Spectraforce Technologies Inc
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