Clinical Review Clinician - Appeals

Spectraforce Technologies, Inc.; Phoenix (AZ); Remote; USD 55,000 - 75,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking a Clinical Review Clinician - Appeals for a remote, national role with preference for AZ-based candidates.

The position reviews claims, determines utilization decisions, and collaborates closely with MD teams to ensure appropriate outcomes for members.

Qualifications

• Requires active RN or LPN license.
• Medicare knowledge required.
• Experience with utilization management or appeals reviews.
• Ability to work in a production-based environment.

Responsibilities

• Review cases with medical directors to finalize decisions.
• Process retrospective claim reviews for utilization management or appeals.
• Collaborate with leadership and senior clinicians for guidance.
• Maintain high quality standards with 95% quality on all cases.

Skills

Utilization Management

Appeals review

Medicare knowledge

RN/LPN licensure

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

Tools

InterQual/Milliman Software

Job description

Job Title: Clinical Review Clinician - Appeals

Duration: 06 months (Possibility for extension or conversion)

Shift Schedule: 8-5 EST or CST time zone-weekend rotation required.

Location: Remote- Nationally sourced. However, would like 1 candidate in AZ

Responsibilities

• Staff will work when there are members of the supervisor/leadership on.
• Cases are assigned in round robin fashion for staff to review and work. Nurses review case files, add, update or edit authorizations.
• Work closely with the MD team to make final decisions on cases.
• The clinical team works closely with their supervisors and senior clinicians on the team for support.
• Team does have group chats on Teams for routine questions.
• Team works closely together along with the coordinator team who owns end to end process on cases.
• Team handles various types of authorization and claim review requests from various markets nationwide. Processing clinical reviews to ensure members have the best outcomes and access to care needed. Help reduce provider abrasion by processing retrospective claim reviews.

Candidate Requirements

Education/Certification

Required

Preferred: Associate in nursing, Bachelor's in nursing or higher.

Licensure

Required: RN, LPN

Preferred: LVN

Key Criteria

• Years of experience required
• Disqualifiers

  Disqualifiers: Not having a valid/active RN/LPN license

• Best vs. average

  Best vs. average: Productivity expectations are set based on platform.

• Performance indicators

  Performance indicators: Productivity expectations vary based on platform. Prime 7 CPD, iCP 9 CPD and CenPas is 20 CPD cases per day with 95% quality on all cases

Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals

Nice to haves: Medicare Appeals Experience

Top Hard Skills

• Top 3 must-have hard skills
• Level of experience with each
• Stack-ranked by importance
• Candidate Review & Selection

1: Utilization Management or Appeals review background (1 plus year)

2: Medicare NCD/LCD and InterQual/Milliman Software (1 plus year)

3: Retrospective claims clinical reviews (1 plus year)