To resolve and process appeals, the full-time Licensed Clinical Review Clinician will perform clinical reviews of medical records and clinical data remotely, ensuring compliance with policies and NCQA standards, while participating in weekend on-call rotations and holiday coverage. Key responsibilities Prepares case reviews for Medical Directors by researching appeals and analyzing applicable criteria Ensures timely review and response to appeals in accordance with State, Federal, and NCQA standards Communicates with members, providers, and facilities regarding appeal requests and generates resolution communications Required qualifications Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing 2 - 4 years of related experience Fully licensed as LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist Knowledge of NCQA, Medicare, and Medicaid regulations preferred Experience in utilization management processes preferred
Licensed Clinical Review Clinician in workfromhome at Unknown Company
This position is listed as full time and able to be worked remotely.