New York Licensed Clinical Reviewer

A company is looking for a Clinical Review Clinician - Appeals.

Key Responsibilities

Performs clinical reviews to resolve and process appeals by analyzing medical records and clinical data

Ensures timely review and response to appeals in accordance with relevant standards

Communicates with members, providers, and other departments regarding appeal requests

Required Qualifications, Training, and Education

Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing

2 - 4 years of related experience

Must have a New York State clinical license (LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist)

Knowledge of NCQA, Medicare, and Medicaid regulations preferred

Knowledge of utilization management processes preferred