New York Licensed Clinical Reviewer

Job Summary

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

Key Responsibilities

• Performs clinical reviews to resolve and process appeals by assessing medical records and clinical data for medical necessity
• Prepares case reviews for Medical Directors and ensures timely processing of appeals in compliance with relevant standards
• Communicates with members, providers, and departments regarding appeal requests and generates resolution communications

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 hold a New York State clinical license (LPN, LVN, RN, LCSW, LMHC, LPC, LMFT, or Licensed Psychologist)
• Knowledge of NCQA, Medicare, and Medicaid regulations preferred
• Familiarity with utilization management processes preferred