Clinical Appeals Specialist

Point32Health, Inc.; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

Point32Health is seeking a Clinical Consultant – Appeals & Grievances to provide clinical support to the Appeals & Grievances team and act as the liaison for clinical issues across internal partners and vendors. You will work independently and with cross-functional groups to address member and provider issues, applying medical terminology and review processes.

This role emphasizes collaboration with analysts, MD reviewers, and cross-functional committees to improve appeal outcomes within managed

Qualifications

• Must have clinical knowledge relevant to appeals and grievances.
• Understanding of managed care review processes and terminology.
• Experience collaborating with analysts and MD reviewers.

Responsibilities

• Serve as clinical resource for Appeal & Grievances work.
• Support Analyst team in medical terminology and care plans.
• Analyze and consult on physician review needs.
• Identify complex members and refer to case management as needed.
• Assess drivers of appeals trends and report to leadership.
• Consult MD reviewers on complex appeals and grievances.
• Assist with case preparation and participate in cross-functional committees.
• Assist trainer with new hire clinical onboarding.
• Perform other duties as assigned.

Skills

Clinical knowledge

Appeals & Grievances

Cross-functional collaboration

Independent worker

Education

MD or DO or equivalent

Job description

Point32Health is seeking a Clinical Consultant – Appeals & Grievances to provide clinical support to the Appeals & Grievances team and act as the liaison for clinical issues across internal partners and vendors. You will work independently and with cross-functional groups to address member and provider issues, applying medical terminology and review processes.

This role emphasizes collaboration with analysts, MD reviewers, and cross-functional committees to improve appeal outcomes within managed