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Clinical Appeals Reviewer, Registered Nurse

Company: Amerihealth
Location: Newark
Posted on: October 13, 2021

Job Description:

Your career starts now. We’re looking for the next generation of health care leaders.

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 health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, 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. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

The Clinical Appeals Reviewer reports to an Appeals and Grievances Supervisor and is responsible for processing appeals and grievances ensuring all milestones are within compliance. 

  • Outreaches to the appellant or their representative and is responsible for obtaining and reviewing medical records and packaging all pertinent information into a case for a determination.   
  • Directly interacts with providers to obtain additional clinical information as well as with members or their advocates to understand the full intent of the appeal or grievance. 
  • Throughout the performance of their duties, the Clinical Appeals Reviewer provide clinical expertise and may make determination of medical necessity for case classifications when necessary and provides a front-line regulatory/compliance function in their evaluation of appeals and grievances. 
  • Receives an appeal or grievance case, prior to assigning to the Clinical Appeal Coordinator, so that Clinical Appeal Coordinator can focus the majority of their time on obtaining appropriate medical records and to ensure the case has a timely, compliant decision. 
  • Responsible for reviewing the final determination and creating the decision letter which must contain required information as dictated by regulatory entities and must be mailed on or before compliance timeframes.
  • At times, may be responsible to present their case to a committee.  
  • Utilizes Interqual criteria and understand how to apply it to Appeals and Grievances reviews.
  • Stays current with department and ACFC policies and procedures.
  • Maintains familiarity and compliance with federal, state and local regulations as well as other regulatory requirements (e.g. NCQA standards) relative to appeal and grievance operations.

Education/ Experience:

  • Associate’s Degree. Bachelor’s Degree preferred.
  • Current and unrestricted Delaware Registered Nurse licensure.
  • 3 or more years’ experience in a related clinical setting.   
  • Working knowledge of Interqual criterion. 
  • Proficiency working in a Windows 10 enviroment and utilizing MS Office including Word, Excel, and Outlook.
  • Proficiency utilizing Electronic Medical Records (EMRs).
  • Familiarity with the appeals and grievances process, preferably within a managed care organization.  
  • Strong verbal and written communication skills, critical thinking skills, presentation skills, and the ability to manage and complete multiple high priority tasks within designated timeframe. 
  • This position will be based out of our Delaware office once our remote work mandate has been lifted.           

 

 

 

 

Keywords: Amerihealth, Newark , Clinical Appeals Reviewer, Registered Nurse, Other , Newark, Delaware

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