Clinical Appeals Reviewer

About AmeriHealth Caritas

AmeriHealth Caritas is a mission-driven healthcare organization with over three decades of experience headquartered in Newtown Square. The company delivers comprehensive, outcome-focused care to vulnerable populations through managed care products, pharmacy benefit management, specialty pharmacy services, behavioral health, and administrative solutions. Our goal is to help people access care, maintain wellness, and foster healthy communities across the nation.

Role Overview

The Clinical Appeals Reviewer position is pivotal in managing appeals by ensuring all regulatory deadlines and compliance requirements are met. Responsibilities include communicating with appellants or their representatives, gathering and analyzing medical records, assembling case files for determinations, collaborating with healthcare providers to secure additional clinical data, engaging members or their advocates to understand the appeal's purpose, and offering clinical judgment to classify cases and determine medical necessity. This role supports regulatory and compliance functions by reviewing appeal cases, facilitating decision-making by Medical Directors, composing decision letters, and presenting cases to committees as needed. The job also requires applying InterQual criteria during appeal assessments and adhering to policies and standards such as NCQA related to appeals and grievance operations.

Responsibilities

• Ensure appeal processing complies fully with regulatory milestones.
• Analyze medical records to identify Hospital-Acquired Conditions (HAC), verify documentation accuracy, coding compliance, and prevent reimbursement mistakes.
• Coordinate with appellants and their representatives to obtain and review relevant clinical documents.
• Compile and organize essential information into cases ready for determination.
• Engage with healthcare providers to acquire supplementary clinical information.
• Work collaboratively with members or their advocates to clarify appeal objectives.
• Apply clinical expertise to assess medical necessity for case classification.
• Conduct front-line regulatory and compliance evaluations of appeals.
• Review appeal cases for Medical Director timely decision-making.
• Draft decision letters containing all required regulatory content.
• Present cases before committees when necessary.
• Use InterQual guidelines in the review process.
• Stay updated with departmental policies and regulatory requirements.

Requirements

• Associate’s Degree in Nursing (ASN) mandatory.
• At least three years of clinical experience related to diagnosis and procedure coding.
• Coding experience is preferred.
• Familiarity with InterQual criteria is required.
• Proficient in Windows 10 and MS Office applications (Word, Excel, Outlook).
• Experience with Electronic Medical Records (EMRs).
• Preferably has managed care appeals process knowledge.
• Must hold a current and unrestricted Registered Nurse (RN) license or compact state licensure.

Skills

• Excellent written and verbal communication capabilities.
• Critical thinking and analytic skills.
• Effective presentation skills.
• Strong organizational and multitasking abilities to prioritize multiple high-importance tasks.

Additional Information

As the position is fully remote, candidates need a stable high-speed internet connection with a minimum of 50 Mbps download and 5 Mbps upload speed to support daily tasks. Associates residing in states with service-related contractual or legal requirements may apply for reimbursement of internet expenses.

AmeriHealth Caritas provides a thorough benefits package, including flexible working arrangements, remote/hybrid options, competitive compensation, paid time off including holidays and volunteer days, comprehensive health insurance coverage effective from the first day of work (including dependents), 401(k) enrollment, and tuition reimbursement.