Clinical Review Clinician - Appeals.

Pyramid Consulting, Inc; Columbus (OH); On-site; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a Clinical Review Clinician for a contract role in Columbus, Ohio. This position involves reviewing medical appeals, determining medical necessity, and ensuring compliance with established guidelines. The ideal candidate will have a strong background in utilization management and appeals, along with excellent communication skills to collaborate effectively with team members. This opportunity not only offers a competitive pay range but also the potential for long-term engagement in the healthcare sector. Join a team dedicated to improving patient outcomes and making a difference in the healthcare landscape.

Benefits

Health insurance (medical, dental, vision)

401(k) plan

Paid sick leave

Qualifications

• 2+ years of experience in Utilization Review/Management.
• Strong skills in medical necessity determination and appeals processes.

Responsibilities

• Perform appeal reviews for medical necessity and document outcomes.
• Determine medical necessity according to NCQA standards.

Skills

RN

Utilization management

Appeals

Medical necessity determination

Microsoft Office

Job description

1 day ago Be among the first 25 applicants

Pyramid Consulting, Inc provided pay range

This range is provided by Pyramid Consulting, Inc. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$30.00/hr - $34.00/hr

Immediate need for a talented Clinical Review Clinician - Appeals. This is a 06+ Months Contract opportunity with long-term potential and is located in Columbus, Ohio (Onsite). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-68236

Pay Range: $30 - $34/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system).
• Behavior and accountability and ability to pivot when new priorities come up.
• Determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
• Emails and Team chats to ensure communication is reached and assistance is available, if needed.

Key Requirements and Technology Experience:

• Skills: RN, Utilization management and Appeals.
• Experience with Utilization Review/Management - 2 yrs.
• Reviews relevant information within denied authorization/prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case.
• Review medical code data and records to determine whether a denial is warranted.
• Utilizing multiple appeals/claims systems to conduct medical reviews.
• Comfortable with Microsoft Office programs and utilizing systems to input medical criteria.

Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.