Clinical Review Clinician - Appeals

Responsibilities: Performs clinical reviews of medical records and data to determine medical necessity for appeals in accordance with NCQA and regulatory standards. Prepares case reviews for Medical Directors and communicates resolutions to members and providers.

Requirements: Requires a nursing degree (RN strongly preferred) or a related clinical license (LCSW, LMHC, LPC, LMFT, or Psychologist) with 2-4 years of related experience. Knowledge of NCQA, Medicare, and Medicaid regulations is preferred.

Key skills: Clinical Review, Medical Necessity Determination, Appeals Processing, Medical Record Review, NCQA Standards, Utilization Management, Case Review, Clinical Data Analysis

Keywords: NCQA, Medicare, Medicaid, Utilization Management, RN, LPN, LVN, LCSW, LMHC, LPC, LMFT, Clinical Appeals, Medical Necessity, Healthcare Compliance, Medical Management