Clinical Review Clinician - Appeals
 Spectraforce Technologies | |||||||
 United States, Ohio, Columbus | |||||||
 May 02, 2025 | |||||||
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Title: Clinical Review Clinician - Appeals Location: Remote (Columbus area, OH Preferred) Duration: 6 Months (Potential to Extend) ? 8a-5p (NO OT req) Position Purpose: 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. (Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system). Behavior and accountability and ability to pivot when new priorities come up Must-Haves: Experience with Trucare and/or Amisys systems is greatly valued. Utilization review nurse, appeal review nurse, and direct patient care experience. Experience with Utilization Review/Management--2 yrs Reviews relevant information within denied authorization/prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case. Review medical code data and records to determine whether a denial is warranted. 10 to 15 appeals a day Nice to have: Direct patient care experience Longevity at positions Writing appeal or authorization outcome letters.
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