Responsibilities:

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 provide 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.
• Receives an appeal or grievance case, prior to assigning to the Coordinator Appeals and Grievances. so that Coordinator Appeals and Grievances can focus the majority of their time on obtaining appropriate medical records and to ensure the case has a timely, compliant decision.
• 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.
• At times, may be responsible to present their case to a committee.
• Utilizes Interqual criteria and understand how to apply it to Appeals and Grievances reviews.
• Stays current with department and ACFC policies and procedures.
• Maintains familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.

Education/Experience:

• Bachelor’s Degree.
• Registered Nurse graduated from an accredited program.
• Current unrestricted Registered Nurse license. Multi-state/compact licensure strongly preferred.
• 3 or more years’ experience in a related clinical setting .