Clinical Review Clinician- Appeals (Remote, Ohio)

Position Title – Clinical Review Clinician- Appeals
Address – Remote OH (Columbus Area preferred)
Pay - $34/hr
Start date – 9/15/25
Hours – M-F, 8-5
Contract Type – 6 month contract with possible ext/conversion
Vaccine Requirement - No

Position Purpose: Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards

Responsibilities:
- Perform appeal review for medical necessity, complete appeal cases (making determination, documenting outcome, sending out letter, and closing out appeal in system
- Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
- Communicates with members, providers, facilities, and other departments regarding appeals requests
- Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
- Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
- Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
- Performs other duties as assigned
- Complies with all policies and standards

Required Skills & Education:
- LPN or RN required
- 2+ years of Utilization review/Management
o Experience with Denied and prior auth cases
o Reviewing medical code data and records to determine if denial is warranted
o Utilizing multiple appeals/claims systems to conduct medical reviews
o Experience with Trucare and/or Amisys systems is greatly valued
- Microsoft office savvy