Posted on: October 13, 2021
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
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.
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
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
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
At times, may be responsible to present their case to a
Utilizes Interqual criteria and understand how to apply it to
Appeals and Grievances reviews.
Stays current with department and ACFC policies and
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.
Associate’s Degree. Bachelor’s Degree preferred.
Current and unrestricted Delaware Registered Nurse
3 or more years’ experience in a related clinical
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
This position will be based out of our Delaware office
once our remote work mandate has been lifted.
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