Clinical Reviewer
Independent Health
full-time
Posted on:
Location Type: Hybrid
Location: Buffalo • New York • 🇺🇸 United States
Visit company websiteSalary
💰 $37 - $40 per hour
Job Level
Mid-LevelSenior
About the role
- responsible for the collection and review of medical records specific to quality complaints/grievances and appeals as indicated in support of a high performing health plan and physician network
- investigate quality complaints/grievances and appeals
- document research of initial coverage determinations
- lead coordination of clinical review with appropriate internal stakeholders and Medical Director
- prepare written responses to appeals and complaints/grievances
- establish plans of correction and provide education to members and providers
- initiate ancillary department referrals in accordance with regulatory standards, clinical criteria, and member benefit contract
Requirements
- Registered Nurse (RN) with active, current, unrestricted NYS license required; BSN preferred
- Certified Coding Specialist (CCS)/AHIMA or Certified Professional Coder (CPC)/AAPC credentials preferred
- Four (4) years of clinical experience required
- Utilization Management experience preferred
- 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
Benefits
- full range of benefits
- generous paid time off
- scorecard incentive
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical experiencecoverage determinationsquality complaintsgrievancesplans of correctionutilization managementmanaged care benefit plansclinical guidelinesattention to detaillogical thinking
Soft skills
verbal communicationwritten communicationinterpersonal communicationinitiativeorganizational skillstime managementflexibilityproblem-solvingescalation handlingarticulation
Certifications
Registered Nurse (RN)Certified Coding Specialist (CCS)Certified Professional Coder (CPC)