Note: The job is a remote job and is open to candidates in USA. Independent Health is a health plan and physician network that values growth, innovation, and collaboration. The Clinical Reviewer is responsible for investigating quality complaints, grievances, and appeals, coordinating clinical reviews, and preparing written responses while ensuring compliance with regulatory standards.
Responsibilities
- 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
Skills
- Registered Nurse (RN) with active, current, unrestricted NYS license required
- Four (4) years of clinical experience required
- 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
- BSN preferred
- Certified Coding Specialist (CCS)/AHIMA or Certified Professional Coder (CPC)/AAPC credentials preferred
- Utilization Management experience preferred
Benefits
- Associates may be eligible for a scorecard incentive
- Full range of benefits
- Generous paid time off
Company Overview