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Clinical Review Clinician - Appeals
Job in
Raleigh, Wake County, North Carolina, 27601, USA
Listed on 2026-02-04
Listing for:
Spectraforce Technologies
Full Time
position Listed on 2026-02-04
Job specializations:
-
Healthcare
Healthcare Nursing, Healthcare Administration
Job Description & How to Apply Below
Position Title: Clinical Review Clinician - Appeals
Work Location: Remote - Nationally sourced (Preference for 2 candidates in AZ)
Assignment Duration: 6 months
Work Schedule: 8:00 AM - 5:00 PM EST or CST
Work Arrangement: Remote
Position SummarySchedule is 8-5 EST or CST hours. Staff will work when there are members of the supervisor/leadership on. Cases are assigned in round robin fashion for staff to review and work.
Background & ContextThe Organization's clinical team handles various types of authorization and claim review requests from various markets nationwide, processing clinical reviews to ensure members have the best outcomes and access to care needed.
Key Responsibilities- Nurses review case files, add, update or edit authorizations.
- Work closely with the MD team to make final decisions on cases.
- Process clinical reviews to ensure members have access to care needed.
- Help reduce provider abrasion by processing retrospective claim reviews.
- Work closely with supervisors, senior clinicians, and the coordinator team on end-to-end case processes.
- Participate in team collaboration via Teams group chats for routine questions.
Associate in nursing, Bachelor's in nursing or higher.
Licensure (Required)RN, LPN
Licensure (Preferred)LVN
Must haves- Medicare knowledge
- Inter Qual or Milliman Experience
- Clinical reviews for Utilization Management or Appeals
- Medicare Appeals Experience
- Not having a valid/active RN/LPN license
- Productivity expectations vary based on platform.
- Prime: 7 CPD
- iCP: 9 CPD
- Cen Pas: 20 CPD cases per day
- 95% quality on all cases
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