Clinical Appeals Reviewer
New
Based in the United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum 3 years
Requirements
- Active license as an RN, PT, OT, RT, or other qualified healthcare professional.
- Minimum 3 years of experience in medical review, Medicare appeals, utilization review, or related clinical decision-making roles.
- Strong knowledge of Medicare regulations, coverage rules, and healthcare compliance frameworks.
- Experience writing medical necessity determinations or clinical review decisions.
- Ability to interpret clinical data, policies, and legal/regulatory documentation.
- Strong analytical, reasoning, and problem-solving skills with high attention to detail.
- Excellent written and verbal communication skills, including professional medical documentation.
- Ability to manage competing priorities and meet strict deadlines in a structured environment.
Responsibilities
- Review medical records and case files to determine medical necessity and appeal outcomes.
- Prepare clear, concise, and well-reasoned reconsideration decision letters supported by clinical evidence.
- Conduct independent clinical reviews aligned with applicable federal laws, Medicare regulations, and policy guidelines.
- Ensure all appeal issues raised by patients, providers, or representatives are fully evaluated and addressed.
- Research medical literature, coverage policies, and regulatory guidance to support determinations.
- Participate in case discussions, quality reviews, and cross-functional meetings as needed.
- Serve as a subject matter resource and support mentoring or training of other staff when required.
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