• Job Description

  Req#: JP-005407390

  Job Description

  As a Clinical Review Clinician specializing in appeals, you will be responsible for preparing case reviews for Medical Directors by thoroughly researching appeals, reviewing applicable criteria, and analyzing the basis for each appeal. You will ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards. This role involves communication with members, providers, facilities, and other departments regarding appeals requests, and generating appropriate resolution communication and reporting for both members and providers.

  Responsibilities

  • Prepare detailed case reviews for Medical Directors by researching appeals and reviewing applicable criteria.
  • Ensure timely review, processing, and response to appeals in accordance with State, Federal, and NCQA standards.
  • Communicate effectively with members, providers, facilities, and other departments regarding appeals requests.
  • Generate appropriate appeals resolution communication and reporting for members and providers.
  • Collaborate with leadership to enhance the consistency, efficiency, and appropriateness of responses to appeals requests.
  • Partner with interdepartmental teams to improve clinical appeals processes and procedures, preventing recurrences based on industry best practices.
  • Perform other duties as assigned, complying with all company policies and standards.

  Essential Skills Needed

  • Proficiency in clinical review, case management, utilization review, and utilization management.
  • Experience with Medical Records and Clinical Data.

  Qualifications

  • Graduate from an Accredited School of Nursing or Bachelor's degree in Nursing.
  • 2-4 years of related experience.
  • Knowledge of NCQA, Medicare, and Medicaid regulations is preferred.
  • Familiarity with utilization management processes is preferred.
  • State Licensure as LPN, LVN, RN, LCSW, LMHC, LPC, Licensed Marital and Family Therapist, or Licensed Psychologist is required.

  Pay and Benefits

  The pay range for this position is $30.00 - $40.00/hr.

  Eligibility requirements apply to some benefits and may depend on your job
  classification and length of employment. Benefits are subject to change and may be
  subject to specific elections, plan, or program terms. If eligible, the benefits
  available for this temporary role may include the following:

  • Medical, dental & vision
  • Critical Illness, Accident, and Hospital
  • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
  • Life Insurance (Voluntary Life & AD&D for the employee and dependents)
  • Short and long-term disability
  • Health Spending Account (HSA)
  • Transportation benefits
  • Employee Assistance Program
  • Time Off/Leave (PTO, Vacation or Sick Leave)

  Workplace Type

  This is a fully remote position.

  Application Deadline

  This position is anticipated to close on Jul 25, 2025.

  About Actalent

  Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

  The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

  If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.

• About the company

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