Overview

The Clinical Reviewer will be responsible for the collection and review of medical records specific to quality complaints/grievances and appeals as indicated in support of a high performing health plan and physician network. The Clinical Reviewer will investigate quality complaints/grievances and appeals, document research of initial coverage determinations, and lead coordination of clinical review with appropriate internal stakeholders and Medical Director. This position will prepare written responses to appeals and complaints/grievances, establish plans of correction and provide education to members and providers. In addition, they will initiate ancillary department referrals in accordance with regulatory standards, clinical criteria, and member benefit contract.

Qualifications

• Registered Nurse (RN) with active, current, unrestricted NYS license required; BSN preferred. Certified Coding Specialist (CCS)/AHIMA or Certified Professional Coder (CPC)/AAPC credentials preferred.
• Four (4) years of clinical experience required. Utilization Management experience preferred.
• Comprehensive knowledge and experience with managed care benefit plans.
• Ability to research and assist clinical team in rendering coverage determinations in accordance with established clinical guidelines and member contracts.
• Excellent verbal, written and interpersonal communication skills required.
• Ability to handle escalated calls and to deliver messages clearly and articulately regarding decisions.
• Ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific clinical and claims platforms.
• Possess initiative, attention to detail, and solid, logical thinking capabilities.
• Ability to manage multiple, time-sensitive priorities and adhere to all deadlines, while remaining organized.
• Ability to work a flexible schedule required.
• Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

Essential Accountabilities

• Thoroughly investigate clinical appeals and complaints/grievances utilizing appropriate internal and external resources to ensure coverage determinations are consistent and within clinical guidelines and member benefit contract. Investigate and research all levels of quality complaints/grievances, appeals, concerns, plans of correction and contractual appeals that require MD decision making independently to ensure decisions are within accordance with applicable policies, procedures, criteria, and contracts. Research standards of care pertaining to medical issues in support of clinical care algorithms. Special projects as assigned.
• Ensure verbal and written responses to quality complaints/grievances, appeals and investigations follow regulatory standards. Create detailed summary of all findings and recommendations for MD review and provide direction and disposition for member complaints and internal concerns, facility and/or physician improvement opportunities. Provide member education and outreach related to coverage determinations and member benefit contract.
• Coordinate and collaborate with ancillary departments and peers within the clinical team in rendering consistent coverage determinations and claims payments in accordance with policy, criteria, and member benefit contract. Demonstrate positive interrelationships and service excellence in performance of duties by meeting or exceeding the expectations of internal and external service groups.
• Coordinate with external agencies to prepare case files when needed for external appeals.
• Thorough and accurate completion of log worksheet to maintain consistency in logging complaints/appeals. Maintain and monitor outstanding case logs to plan and prioritize workload. Monitor daily reports to ensure accuracy and timeliness of complaints/grievances and appeals. Identify appeal trends and process improvements where applicable.
• Based on measurement and evaluation of clinical appeal data, assist in continuously developing systems, workflows, and coverage criteria to better meet the needs of the customer.
• Assist in meeting department goals and objectives and identify process improvements to continuously improve member/provider satisfaction. Attend assigned meetings as department representative and report to team members when necessary.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $38.00 - $41.00 hourly

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

Current Associates must apply internally via the Job Hub.