Clinical

Position Title: Clinical Review Clinician - Appeals

Work Location: Remote - Ohio (Columbus area preferred) Assignment Duration: 6 months Work Schedule: 8a-5p (NO OT required) Work Arrangement: Remote Position Summary:

• Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system).
• Behavior and accountability and ability to pivot when new priorities come up.
• Emails and Team chats to ensure communication is reached and assistance is available, if needed.

Candidate Requirements: Education/Certification

• Required: LPN Minimum
• Preferred: RN - Not required

Licensure

• Required: LPN minimum

Nice to Haves:

• Direct patient care experience
• Longevity at positions
• Writing appeal or authorization outcome letters
• Experience with Trucare and/or Amisys systems is greatly valued
• Utilization review nurse, appeal review nurse and direct patient care experience

Disqualifiers:

• Not possessing the must haves

Performance Indicators (Metrics):

• 10 to 15 appeals a day after training
• Not letting any items in work queues go over compliance Turn Around Time

Candidate Requirements Education/Certification Required: LPN Minimum Preferred: RN-Not required Licensure Required: LPN minimum Preferred: Years of experience required Disqualifiers Best vs. average Performance indicators Must haves: (SEE NUMBERED SECTION BELOW) Nice to haves: Direct patient care experience Longevity at positions Writing appeal or authorization outcome letters. experience with Trucare and/or Amisys systems is greatly valued.

• Utilization review nurse, appeal review nurse and direct patient care experience.

Disqualifiers: Not possessing the must haves Performance indicators: (Metrics: *10 to 15 appeals a day after training. Not letting any items in work queues go over compliance Turn Around Time.) Best vs. average: Top 3 must-have hard skills Level of experience with each Stack-ranked by importance Candidate Review & Selection 1 Experience with Utilization Review/Management--2 yrs 2 Reviews relevant information within denied authorization/prior authorization case to ensure a complete case summary is provided to the Medical Director for review of the appeal case. 3 Review medical code data and records to determine whether a denial is warranted. 4 Utilizing multiple appeals/claims systems to conduct medical reviews. 5 Comfortable with Microsoft office programs and utilizing systems to input medical criteria. SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at [email protected] if you require reasonable accommodation.