Clinical - Clinical Review Clinician - Appeals - J00923

Job Description:

Job Title: Clinical Review Clinician- Appeals

Duration: 6 months (Possible Extension)

Location: Remote

Shift: Day 5x8-Hour (08:00AM - 05:00PM) EST or CST

Position Overview:

Seeking Licensed RNs or LPNs to join our Shared Services Medicare Appeals Department. The Clinical Review Clinician will perform clinical reviews for pre-service authorization denials and retrospective claim denials for both members and providers. These reviews ensure access to medically necessary services and reduce provider abrasion.

This fully remote position offers the opportunity to work within a high-performing, collaborative clinical team, supporting national Medicare operations and making impactful decisions that improve patient outcomes.

Key Responsibilities:

• Conduct clinical reviews for authorization and claim denial appeals.

• Analyze clinical documentation to determine medical necessity in accordance with Medicare policies.

• Use InterQual, Milliman, and Medicare NCD/LCD criteria for decision-making.

• Collaborate closely with Medical Directors and senior clinical staff for final determinations.

• Accurately add, update, and edit case authorizations in internal platforms.

• Maintain a daily productivity standard (e.g., Prime: 7 CPD, iCP: 9 CPD, CenPas: 20 CPD) with 95% quality compliance.

• Communicate effectively within a supportive team environment using MS Teams and other tools.

Required Qualifications:

• Active and unrestricted RN or LPN license (LVN accepted as a preferred alternative).

• Associate's Degree in Nursing or higher (Bachelor's preferred).

• 1+ year experience in Utilization Management or Appeals reviews.

• Proficiency with Medicare NCD/LCD guidelines.

• Hands-on experience with InterQual and/or Milliman criteria tools.

• Experience conducting retrospective claims clinical reviews.

Preferred Qualifications:

• Prior Medicare Appeals experience.

• Familiarity with Centene platforms such as Prime, iCP, and CenPas.

Key Skills & Competencies (Ranked by Priority):

1. Utilization Management / Appeals Review minimum 1 year required

2. Medicare Policy Interpretation + InterQual/Milliman minimum 1 year

3. Retrospective Clinical Claims Review minimum 1 year

Work Environment & Culture:

• Nationally distributed team of 30+ clinicians.

• Cases assigned on a rotating (round robin) basis.

• Daily collaboration with MD team, supervisors, and senior clinicians.

• Supportive, team-driven culture with strong communication via Teams.

• Low supervision environment, but leadership support readily available.