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Title
Text copied to clipboard!Clinical Appeals Reviewer
Description
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We are looking for a Clinical Appeals Reviewer to join our healthcare team and play a critical role in ensuring the integrity and accuracy of clinical appeal decisions. This position involves reviewing denied medical claims and appeals submitted by healthcare providers or patients, assessing the medical necessity, appropriateness, and compliance with regulatory and policy guidelines. The Clinical Appeals Reviewer will collaborate with physicians, nurses, and other healthcare professionals to gather relevant clinical documentation and make informed decisions based on evidence-based guidelines and payer policies.
The ideal candidate will have a strong clinical background, excellent analytical skills, and a deep understanding of healthcare regulations, including Medicare, Medicaid, and commercial insurance policies. This role requires attention to detail, the ability to interpret complex medical records, and strong written communication skills to articulate the rationale for appeal decisions. The Clinical Appeals Reviewer will also be responsible for maintaining accurate records, meeting deadlines, and ensuring that all appeal reviews are conducted in a fair, unbiased, and timely manner.
This is a vital position within the healthcare system, as it directly impacts patient access to care and provider reimbursement. The successful candidate will demonstrate professionalism, integrity, and a commitment to upholding the highest standards of clinical review. Experience in utilization management, case management, or medical coding is highly desirable. This role may be remote or on-site, depending on the employer’s needs.
Responsibilities
Text copied to clipboard!- Review clinical documentation and medical records for appeal cases
- Evaluate denied claims for medical necessity and policy compliance
- Collaborate with healthcare providers to obtain additional information
- Apply evidence-based guidelines and payer policies to appeal decisions
- Document findings and decisions clearly and accurately
- Ensure timely processing of appeals within regulatory deadlines
- Participate in quality assurance and audit activities
- Maintain confidentiality and compliance with HIPAA regulations
- Communicate appeal outcomes to internal and external stakeholders
- Stay updated on changes in healthcare regulations and payer requirements
Requirements
Text copied to clipboard!- Registered Nurse (RN) or other clinical licensure required
- Minimum of 3 years of clinical experience in a healthcare setting
- Experience in utilization review, case management, or appeals preferred
- Strong knowledge of medical terminology and clinical guidelines
- Familiarity with Medicare, Medicaid, and commercial insurance policies
- Excellent analytical and critical thinking skills
- Strong written and verbal communication abilities
- Proficiency in using electronic medical records and review systems
- Ability to work independently and manage multiple cases
- Attention to detail and commitment to accuracy
Potential interview questions
Text copied to clipboard!- Do you have a current RN or clinical license?
- How many years of clinical experience do you have?
- Have you worked in utilization review or appeals before?
- Are you familiar with Medicare and Medicaid guidelines?
- Can you describe your experience with medical record review?
- What tools or systems have you used for clinical documentation?
- How do you ensure accuracy in your reviews?
- Are you comfortable working independently and meeting deadlines?
- What is your approach to handling complex or ambiguous cases?
- Are you open to remote work or relocation if required?
