Licensed Medical Necessity Independent Medical Reviewer Clinical Appeals Consultant

Job Summary

A company is looking for an Independent Medical Reviewer - Clinical Appeals Consultant - Medical Necessity.

Key Responsibilities:

• Conduct in-depth medical record reviews for revenue recoupment opportunities
• Provide well-written appeal arguments based on clinical evidence and payers' clinical policy bulletins
• Offer Root Cause analyses and Performance Improvement Recommendations to educate clients on preventing further denials

Required Qualifications:

• Graduate of accredited Nursing or Medical Discipline program with appropriate corresponding licensure
• Knowledge and experience with evidence-based inpatient guidelines and criteria
• Understanding of medical necessity and authorization requirements for inpatient and outpatient cases
• Knowledge of third-party payer requirements for reimbursable care
• At least 3 years of clinical experience