Professional - Appeals Clinician I

Title: Professional - Appeals Clinician I (B03724)

Location: Remote, OR, US

Job Description:

Job#: 3027339

Professional - Appeals Clinician I

Employment Type: Contract

Employee Type:
Contract

Job Type:

Pay Range: $25 - $28 per hour

Role Overview

The Appeals Clinician I utilizes clinical expertise to complete the clinical component of all appeal types to resolve member and/or provider appeals. This role applies nursing expertise and clinical judgment to ensure written appeal decisions are compliant with medical policy, medical necessity guidelines, reimbursement policies, federal regulations, and accepted standards of care.

Key Responsibilities

• Apply nursing expertise and clinical judgement to ensure written appeal decisions are in compliance with medical policy, medical necessity guidelines, and reimbursement policies.
• Conduct clinical appeal reviews which adhere to member benefits and provider and hospital contracts.
• Consult with physician advisers to ensure clinically appropriate determinations when required.
• Advise and educate non-clinical appeals staff on clinical cases.
• Prepare and present clear and concise written narratives and decisions.
• Interpret medical records, patient data, and member benefits to communicate complex topics with clinical and non-clinical staff.

Required Qualifications

Education:
Must have at least one of the following:

• Bachelor’s degree (or higher) in a health or human services-related field. A psychiatric RN or Master's degree in Behavioral Health is preferred for behavioral health appeals management.
• Registered nurse (RN) license with a current unrestricted RN license in Oregon, Washington, Idaho, or Utah.

Experience:

• Two years of experience in health insurance, Utilization Management, or Appeals Clinical review.
• Three years (or full-time equivalent) of direct clinical care experience.
• Demonstrated competency in claim review and experience using billing and claims forms.

Skills and Knowledge:

• Proven knowledge of medical and surgical procedures and other healthcare practices.
• Familiarity with rules applied to appeals by accrediting bodies, state and federal governments, and employer groups.
• Knowledge of personal computer software, such as Microsoft Word.
• Knowledge of CPT, ICD-9, and HCPCS coding and Milliman Care Guidelines (MCG).

Work Environment

This is a remote position. Candidates must be willing to work Pacific Time Zone hours. The contractor will be provided with company equipment and must have a supported Internet Service Provider (CATV/Cable Modem, DSL, or Fiber). Satellite or mobile WiFi internet connectivity is not supported.

Apex Systems is a world-class IT services company that serves thousands of clients across the globe. When you join Apex, you become part of a team that values innovation, collaboration, and continuous learning. We offer quality career resources, training, certifications, development opportunities, and a comprehensive benefits package. Our commitment to excellence is reflected in many awards, including ClearlyRated's Best of Staffing® in Talent Satisfaction in the United States and Great Place to Work® in the United Kingdom and Mexico. Apex uses a virtual recruiter as part of the application process. Click here for more details.

Apex Benefits Overview: Apex offers a range of supplemental benefits, including medical, dental, vision, life, disability, and other insurance plans that offer an optional layer of financial protection. We offer an ESPP (employee stock purchase program) and a 401K program which allows you to contribute typically within 30 days of starting, with a company match after 12 months of tenure. Apex also offers a HSA (Health Savings Account on the HDHP plan), a SupportLinc Employee Assistance Program (EAP) with up to 8 free counseling sessions, a corporate discount savings program and other discounts. In terms of professional development, Apex hosts an on-demand training program, provides access to certification prep and a library of technical and leadership courses/books/seminars once you have 6+ months of tenure, and certification discounts and other perks to associations that include CompTIA and IIBA. Apex has a dedicated customer service team for our Consultants that can address questions around benefits and other resources, as well as a certified Career Coach. You can access a full list of our benefits, programs, support teams and resources within our ‘Welcome Packet’ as well, which an Apex team member can provide.