Job Description

Role Overview:

The Clinical Appeals Reviewer is responsible for processing appeals and ensuring all milestones are met in compliance with regulatory requirements. This role involves outreach to appellants or their representatives, obtaining and reviewing medical records, packaging pertinent information into a case for determination, interacting directly with providers to obtain additional clinical information, and with members or their advocates to understand the full intent of the appeal.

Responsibilities:

• Process appeals, ensuring compliance with all regulatory milestones

• Review medical records to identify Hospital-Acquired Conditions (HAC), ensure proper documentation, billing code compliance, and prevent reimbursement errors

• Outreach to appellants or their representatives to obtain and review medical records

• Package pertinent information into a case for determination

• Interact with providers to obtain additional clinical information

• Engage with members or their advocates to understand the full intent of the appeal

• Provide clinical expertise and determine medical necessity for case classifications when necessary

• Perform front-line regulatory/compliance functions in the evaluation of appeals

• Review appeal cases and ensure the Medical Director makes timely decisions

• Review final determinations and create decision letters containing required information as regulatory entities dictate

• Present cases to committees when necessary

• Utilize InterQual criteria and apply them to appeals reviews

• Stay current with the department and AmeriHealth Caritas policies and procedures

• Familiarize yourself with and comply with federal, state, and local regulations, such as the National Committee Quality Assurance (NCQA) standards related to appeal and grievance operations

Education & Experience:

• Associate's Degree in Nursing (ASN) required

• 3 or more years of experience in a related clinical setting and working with diagnosis procedure codes

• Coding experience preferred

• Working knowledge of InterQual criteria

• Proficiency in a Windows 10 environment and utilizing MS Office, including Word, Excel, and Outlook

• Proficiency in utilizing Electronic Medical Records (EMRs)

• Familiarity with the appeals process, preferably within a managed care organization

• Licensure: Current and unrestricted Registered Nurse (RN) licensure or compact state licensure

Skills & Abilities:

• Strong verbal and written communication, critical thinking, presentation, and the ability to manage and complete multiple high-priority tasks within designated timeframes.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

Why Join Us : Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you are driven to make a difference, we want to hear from you.

About AmeriHealth Caritas

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.

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