Clinical Review Clinician - Appeals

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote-USA

Assignment Duration: 7 months

Work Schedule: 8-hour days. OT is voluntary when available. No OT in training.

Work Arrangement: Remote

Position Summary: 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.

Background & Context:

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  This team reviews provider disputes/appeals. The team is fully collaborative via a group chat on Teams. It is an inclusive and supportive environment. Many of the nurses have been on the team for 5+ years.

  
  
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  No additional needs at this time. 6
  
  Key Responsibilities:

  
  
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  Productivity metrics are 8 reviews on average per day once out of training. Appeals are for all lines of business (Medi-Cal, Medicare, and commercial) and all inpatient and outpatient services. In this role, there is no member or provider interfacing. No phone calls, no faxes, no letter writing. The nurses get a daily assignment to help them prioritize their workload.
  
  Qualification & Experience:

  
  
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  Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

  
  
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  Knowledge of NCQA, Medicare and Medicaid regulations preferred.

  
  
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  Knowledge of utilization management processes preferred.
  
  License/Certification:

  
  
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  LPN - Licensed Practical Nurse - State Licensure required or

  
  
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  LVN - Licensed Vocational Nurse required or

  
  
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  RN - Registered Nurse - State Licensure and/or Compact State Licensure required or

  
  
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  LCSW- License Clinical Social Worker required or

  
  
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  LMHC-Licensed Mental Health Counselor required or

  
  
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  LPC-Licensed Professional Counselor required or

  
  
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  Licensed Marital and Family Therapist (LMFT) required or

  
  
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  Licensed Psychologist required

  
  
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  For Health Net of California: RN license required
  
  Candidate Requirements (additional lines from JD):

  
  
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  Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.

  
  
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  Required: CA RN required

  
  
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  Years of experience required: 3 years' UM experience.

  
  
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  Disqualifiers: No UM experience

  
  
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  Additional qualities to look for: Appeals experience preferred. Knowledge and use of InterQual is also preferred.
  
  Top 3 must-have hard skills stack-ranked by importance:

  
  

1. 
   

   Computer literacy

   
   
2. 
   

   Curiosity

   
   
3. 
   

   Excellent communication skills

   
   
   
   
   
   
   

   Candidate Requirements
   Education/Certification	Required: Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.	Preferred:
   Licensure	Required: CA RN required	Preferred: N/A
   Years of experience required: 3 years' UM experience. Disqualifiers: No UM experience Additional qualities to look for: Appeals experience preferred. Knowledge and use of InterQual is also preferred.
   Top 3 must-have hard skills stack-ranked by importance	1	Computer literacy
   2	Curiosity
   3	Excellent communication skills