PHRN and Medical Allied
Core
Process Medicare appeals and conduct clinical reviews for utilization management cases to ensure timely resolution and compliance with CMS guidelines.
Role type
Appeals PHRN Specialist (Utilization Management)
Builds
Clinical review decisions and appeal resolutions for Medicare members
Domain
Healthcare / Medicare Utilization Management
Required skills
Medicare UM and Appeals processes, CMS guidelines, InterQual/MCG criteria, clinical review standards, clinical platforms, Microsoft Office Suite
Preferred skills
Case investigation, validation, critical thinking, written and verbal communication in English, attention to detail, empathy, sound clinical judgment
Responsibilities
Review and process appeal requests for Medicare members, conduct case validation and clinical review, collaborate with payer nurses and IROs, provide clear documentation and clinical rationales, manage multiple cases concurrently, stay current on CMS guidelines and regulatory updates
Seniority
Individual Contributor, operational level