Clinical Review Clinician - Appeals

Spectraforce Technologies; Columbus (OH); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Clinical Review Clinician to handle appeals with a focus on medical necessity. This remote position emphasizes the importance of clinical expertise and the ability to adapt to evolving priorities. You will be responsible for reviewing medical records, processing appeals, and ensuring compliance with industry standards. The role offers a chance to make a significant impact in healthcare by ensuring that decisions are made based on thorough evaluations. If you have a strong background in utilization review and a passion for patient care, this opportunity is perfect for you.

Qualifications

• At least 2 years of Utilization Review/Management experience.
• Experience with Trucare and/or Amisys systems is highly valued.

Responsibilities

• Perform clinical reviews to resolve and process appeals.
• Review medical records to determine medical necessity.

Skills

Utilization Review

Clinical Review

Trucare

Amisys

Direct Patient Care

Education

LPN

RN

Tools

Trucare

Amisys

Job description

Title: Clinical Review Clinician - Appeals

Location: Remote (Columbus area, OH Preferred)

Duration: 6 Months (Potential to Extend)

Schedule: 8a-5p (NO OT req)

Position Purpose:

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.

Responsibilities include appeal review for medical necessity, completing appeal cases (making determinations, documenting outcomes, sending out letters, and closing out appeals in the system).

Requires strong behavior, accountability, and the ability to adapt when new priorities emerge.

Must-Haves:

• Experience with Trucare and/or Amisys systems is highly valued.
• Utilization review nurse, appeal review nurse, and direct patient care experience.
• At least 2 years of Utilization Review/Management experience.
• Review relevant information within denied authorization/prior authorization cases to ensure complete case summaries are provided to the Medical Director for appeal review.
• Review medical code data and records to assess the validity of denials.
• Process approximately 10 to 15 appeals daily.

Nice to Have:

• Direct patient care experience.
• Longevity at previous positions.
• Experience in writing appeal or authorization outcome letters.

Education and Certification:

Required:	LPN Minimum
Preferred:	RN - Not required

Licensure:

Required:	LPN minimum
Preferred:	None specified