BPO Clinical Review Specialist

Job description

Performs training and provides subject matter expertise on clinical reviews needed to resolve and process appeals to team members. • Reviews medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards. Roles and Responsibilities: • Provides guidance on preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. • Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. • Ensures timely review, accurate processing, and response to appeal in accordance with State, Federal and NCQA standards. • May also perform clinical reviews. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation. • Communicates with providers, facilities and other departments regarding appeal requests. • Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal an d NCQA standards. • Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeal requests. • Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices. • Individuals have a well-rounded knowledge of the policies and procedures for appeals processing, specifically for Medicaid and medical necessity review. • Uses sound judgement, especially in non-routine appeals, to make decisions to keep the appeal process moving forward in accordance with contractual timeliness standards. • Maintain files on individual appeals by gathering, analyzing and reporting verbal and written member and provider appeals. • 1-3 years of experience in processing appeals or utilization management. • 1 yr experience in advanced roles such as team lead, trainer, SME, or QA • RN - Registered Nurse - State required Licensure and/or Compact State Licensure • Knowledge of utilization management process • Knowledge of NCQA, Medicaid requlations • Good communication (Demonstrate strong reading comprehension and writing skills) • Able to work independently, strong analytic skills • Required shift timings - US daytime