The Clinical Appeals Specialist is responsible for managing client medical necessity denials for multiple service lines (Eating Disorder Treatment, Substance Abuse Treatment, and Mental Health Treatment) by conducting a
comprehensive analytic review of clinical documentation to determine if an appeal is warranted per state and Federal guidelines. Where warranted, the Clinical Appeals Specialist will write sound, compelling factual arguments. The Clinical Appeals Specialist will also handle audit-related correspondence and other administrative duties as required.                                                        This is a full-time remote opportunity
Essential Job Functions:
Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge
of payer requirements to determine why cases are denied and whether an appeal is required.
Logs, tracks, and processes appeals and grievances. Conducts pertinent research in order to evaluate, respond
to, and close appeals. Builds case files for each grievance and ensures compliance with organizational and
regulatory guidelines.
Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported
appeal arguments.
Interact with Supervisors, Manager, Medical Directors, Case Management, Precertification, Legal, Member
Services and other departments in facilitating identification and resolution of grievances.
Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing
library of clinical references and/or regulatory arguments.
Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
Discuss documentation-related and level of care decisions as required.
Proficiently read and understand abstract information from handwritten patient medical records.
Ensure compliance with HIPAA regulations, to include confidentiality, as required.
Responsible for compliance with all regulatory and department timelines.
Must be able to organize, plan and implement the functions of Member Appeals and Grievances, maintain
timelines and turnaround times to meet multiple requirements/regulations established by external regulating
bodies and applicable state and federal laws
Requires ability to understand and be compliant with State and Federal regulations.
