Clinical Review Clinician - Appeals

You could be the one who changes everything for our 28 reputed company members as a clinical reputed company on our Medical Management/Health Services team. reputed company is a reputed company, national organization offering competitive benefits including a fresh perspective on workplace flexibility. RN Strongly Preferred - Compact RN License Required 100% Remote Business Hours are 8a - 6p CST. Shifts include one weekend day 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 reputed company Assurance (NCQA) standards. • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable reputed company, and analyzing the reputed company for the appeal • Ensures reputed company review, processing, and response to appeal in accordance with State, Federal and NCQA standards • Communicates with members, providers, facilities, and other departments regarding appeals requests • Generates appropriate appeals reputed company communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of reputed company appeals requests • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices • Performs other duties as assigned • Complies with reputed company policies and standards Education/Experience: Requires Graduate from an Accredited School of Nursing or Bachelor’s degree in Nursing and 2 – 4 years of reputed company experience. Knowledge of NCQA, Medicare and reputed company regulations preferred. Knowledge of utilization management processes preferred. License/Certification: • LPN - Licensed Practical reputed company - State Licensure required or • LVN - Licensed Vocational reputed company required or • RN - Registered reputed company - State Licensure and/or Compact State Licensure required or • LCSW- License Clinical reputed company Worker required or • LMHC-Licensed Mental Health Counselor required or • LPC-Licensed reputed company Counselor required or • Licensed Marital and Family Therapist (LMFT) required or • Licensed Psychologist required Pay reputed company: $27.02 - $48.55 per hour reputed company offers a comprehensive benefits package including: reputed company, health insurance, 401K and stock purchase plans, tuition reimbursement, reputed company time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-reputed company factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. reputed company is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or other characteristic protected by applicable law. reputed company applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance reputed company Apply tot his job Apply To this Job