Clinical Review Clinician - Appeals

Davita Inc.; Columbus (OH); Remote; USD 55,000 - 75,000; Full time

Job summary

A leading healthcare company seeks a Clinical Review Clinician - Appeals to perform clinical reviews and resolve appeals. The role requires an LPN, with an RN preferred, and emphasizes collaboration and effective communication within a remote setting in Ohio.

Qualifications

• LPN is required, RN is preferred.
• At least 2 years of utilization review/management experience needed.
• Experience with appeals review and patient care is desirable.

Responsibilities

• Review appeals for medical necessity and document outcomes.
• Communicate decisions and maintain professionalism.
• Adapt to changing priorities effectively.

Skills

Direct patient care experience

Utilization review

Appeals review

Communication

Education

LPN

RN

Tools

Trucare

Amisys

Microsoft Office

Job description

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote in Ohio - Columbus area preferred

Assignment Duration: 6 months

Work Schedule: 8 am - 5 pm

Position Summary:

Performs clinical reviews to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services following policies, guidelines, and NCQA standards.

Background & Context:

• Works closely with team members and supervisors to ensure support and collaboration.
• Performs clinical reviews to determine medical necessity for services according to policies, guidelines, and NCQA standards.

Key Responsibilities:

• Review appeals for medical necessity, complete appeal cases, document outcomes, and communicate decisions.
• Maintain professionalism, accountability, and flexibility to adapt to new priorities.
• Use emails and team chats for effective communication and assistance.

Qualifications & Experience:

• Required: LPN minimum
• Preferred: RN (not required)
• Additional desirable skills include direct patient care experience, experience with Trucare and/or Amisys systems, and experience in utilization review or appeals review roles.

Performance Indicators:

• Handle 10 to 15 appeals daily post-training.
• Ensure timely processing without exceeding compliance turnaround times.

Additional Experience:

1. At least 2 years of utilization review/management experience.
2. Ability to review denial cases thoroughly and provide complete summaries for medical director review.
3. Review medical codes and records to assess denial validity.
4. Proficient with multiple appeals and claims systems.
5. Comfortable with Microsoft Office and medical data entry systems.