Clinical Appeals Reviewer

Amerihealth Caritas•,

1d•Hybrid

About The Position

The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory requirements. This role involves outreach to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full intent of the appeal. At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation’s leaders in healthcare solutions, we offer our associates the opportunity to impact millions of lives through our national footprint of products, services, and award-winning programs. If you want to make a difference, we’d love to hear from you. Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our offerings include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Requirements

Associate's Degree in Nursing (ASN) required
3 or more years of experience in a related clinical setting and working with diagnosis procedure codes
Working knowledge of InterQual criteria
Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook
Proficiency in utilizing Electronic Medical Records (EMRs)
Familiarity with the appeals process, preferably within a managed care organization
Current and unrestricted Registered Nurse (RN) licensure or compact state licensure
Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-priority tasks within designated timeframes.

Nice To Haves

Coding experience preferred

Responsibilities

Process appeals, ensuring compliance with all regulatory milestones
Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors
Outreach to appellants or their representatives to obtain and review medical records
Package pertinent information into a case for determination
Interact with providers to obtain additional clinical information
Engage with members or their advocates to understand the full intent of the appeal
Provide clinical expertise and determine medical necessity for case classifications when necessary
Perform front-line regulatory/compliance functions in the evaluation of appeals
Review appeal cases and ensure the Medical Director makes timely decisions
Review final determinations and create decision letters containing required information as regulatory entities dictate
Present cases to committees when necessary
Utilize InterQual criteria and apply them to appeals reviews
Stay current with the department and AmeriHealth Caritas policies and procedures
Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations