Job Title: Clinical Appeals Specialist
Job Purpose:
The Clinical Appeals Specialist conducts research, analysis, and evaluation of member and provider disputes related to adverse coverage decisions. This role requires clinical expertise and a deep understanding of applicable State and Federal regulations governing appeal processes for Commercial and Government Programs. The Clinical Appeals Specialist ensures professional and compliant responses to appeal requests, upholding organizational policies and regulatory standards.
Key Responsibilities:
- Appeal Investigation and Response (35%):
- Investigate, interpret, and analyze written appeals and reconsideration requests from various sources, including applicants, subscribers, attorneys, and internal stakeholders.
- Draft detailed, compliant, and professional responses to appeal requests while adhering to State and Federal mandates.
- Case Preparation and Physician Review (35%):
- Organize appeal cases for physician review, compiling clinical, contractual, medical policy, and claims data.
- Formulate recommendations for case disposition and communicate final decisions to members and providers, including external appeal rights.
- Clinical Analysis and Collaboration (25%):
- Utilize nursing expertise and available clinical information to assess the appropriateness of adverse coverage decisions.
- Collaborate with Independent Review Organizations and panel physicians to obtain expert clinical opinions.
- Knowledge Management and Regulatory Compliance (5%):
- Maintain and continuously expand knowledge of current medical practices, terminology, and procedural standards.
- Ensure compliance with regulatory and accreditation requirements throughout the appeals process.
Qualifications:
- Education: High School Diploma required; BSN/MSN preferred.
- Experience:
- Minimum 2 years of medical-surgical or clinical experience, OR 3 years in a mental health or psychiatric setting.
- Preferred: 2 years of experience in Medical Review, Utilization Management, or Case Management within a managed care organization or hospital.
- Licenses/Certifications:
- RN - Registered Nurse licensure required.
- Preferred: CCM (Certified Case Manager) or LNCC (Legal Nurse Consultant Certified).
Knowledge, Skills, and Abilities (KSAs):
- Advanced understanding of medical terminology and regulatory/accreditation requirements.
- Proficiency in Microsoft Office programs and appeals-related systems software.
- Strong verbal and written communication, critical thinking, and problem-solving skills.
- Ability to assess medical necessity and appropriateness of care, including for mental health and substance use disorders.
- Demonstrated ability to provide exceptional customer service and manage multiple priorities in a fast-paced environment.
Work Environment:
This role requires adaptability to shifting deadlines and workloads, with the ability to meet service excellence expectations for both internal and external stakeholders.
