Job Description

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Role Overview: ; The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory requirements. This role involves outreach to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full intent of the appeal.

Work Arrangement

• Hybrid in Philadelphia

Responsibilities

• Process appeals, ensuring compliance with all regulatory milestones
• Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors;
• Outreach to appellants or their representatives to obtain and review medical records
• Package pertinent information into a case for determination
• Interact with providers to obtain additional clinical information
• Engage with members or their advocates to understand the full intent of the appeal
• Provide clinical expertise and determine medical necessity for case classifications when necessary
• Perform front-line regulatory/compliance functions in the evaluation of appeals
• Review appeal cases and ensure the Medical Director makes timely decisions;
• Review final determinations and create decision letters containing required information as regulatory entities dictate
• Present cases to committees when necessary
• Utilize InterQual criteria and apply them to appeals reviews
• Stay current with the department and AmeriHealth Caritas policies and procedures
• Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations

Education & Experience

• Bachelor's degree (BSN) required
• 3 or more years of experience in a related clinical setting and working with diagnosis procedure codes
• Coding experience preferred;
• Working knowledge of InterQual criteria
• Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook
• Proficiency in utilizing Electronic Medical Records (EMRs)
• Familiarity with the appeals process, preferably within a managed care organization

Licensure

• Current and unrestricted Registered Nurse (RN) licensure or compact state licensure

Skills & Abilities

• Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-priority tasks within designated timeframes.

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Your career starts now. We’re looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.

As a Company, We Support Internal Diversity Through

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.

If you have questions about this posting, please contact support@lensa.com

Job Tags

Full time, Local area, Flexible hours,

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