Clinical Review Clinician - Appeals

Spectraforce Technologies; Raleigh (NC); Remote; USD 34,000 - 52,000; Part time

Job summary

Spectraforce Technologies, Inc. is seeking a part-time Clinical Review Clinician to perform appeals reviews remotely across the US. The role supports the Medicare Appeals department, with a focus on determining medical necessity and aligning with NCQA standards.

Ideal candidates have RN or LPN licensure and 2–4 years of related experience, plus knowledge of NCQA/Medicare regulations and utilization management. Flexible 20-hour weeks are available, with schedule consistency required.

Qualifications

• Requires RN or LPN license with state licensure.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• Must have Medicare knowledge; InterQual or Milliman experience helpful.
• Retrospective claims clinical reviews experience preferred.
• Not having a valid/active RN/LPN license is a disqualifier.

Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal and analyzing the basis for the appeal.
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards.
• Communicates with members, providers, facilities, and other departments regarding appeals requests.
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards.
• Works with leadership to increase consistency, efficiency, and appropriateness of responses of all appeals requests.
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

NCQA knowledge

Medicare/Medicaid regulations

Utilization management processes

Education

RN/LPN license

Advanced licenses (LCSW/LMHC/LMFT/LP C/Physician)

Job description

Position Information

Position Title: Clinical Review Clinician - Appeals
Work Location: Remote - Nationally sourced
Assignment Duration: 4 months
Work Schedule: 8-5 EST or CST time zone-weekend rotation required.
Work Arrangement: Remote
This is a part time role with 20 hour work weeks. When the schedule is agreed upon, they must work that schedule. They can work 5 days a week, 5 hours per day or they can work 3 days a week to hit their 20 hours. Example: if the candidate chooses MWF they cannot change it up after it is approve. It must remain consistent.

Position Summary

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.
Background & Context: Shared Services Medicare Appeals department. Team of 30 plus clinicians who perform clinical reviews for pre-service authorization denials as well as retrospective claim denials for both members and providers. These reviews determine if members can/did receive medically necessary services. Department is launching a BPO with expected team impacts. Resignations have come in and the need for this request is to mitigate staff leaving until BPO is up and running.

Key Responsibilities

• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
• Communicates with members, providers, facilities, and other departments regarding appeals requests
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

Qualification & Experience

• Requires Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing and 2 - 4 years of related experience.
• Knowledge of NCQA, Medicare and Medicaid regulations preferred.
• Knowledge of utilization management processes preferred.
• License/Certification: LPN - Licensed Practical Nurse - State Licensure required or LVN - Licensed Vocational Nurse required or RN - Registered Nurse - State Licensure and/or Compact State Licensure required or LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Psychologist required

Candidate Requirements

• Education/Certification
  Required: RN, LPN
  Preferred: Associate in nursing, Bachelor's in nursing or higher.
• Licensure
  Required: RN, LPN
  Preferred: LVN
• Must haves: Medicare knowledge, InterQual or Milliman Experience, Clinical reviews for Utilization Management or Appeals
• Nice to haves: Medicare Appeals Experience
• Disqualifiers: Not having a valid/active RN/LPN license
• 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
• Best vs. average: Productivity expectations are set based on platform.
• Top 3 must-have hard skills stack-ranked by importance
• 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)