Retrospective Clinical Review & Appeals Specialist (Remote)

The Retrospective Clinical Review & Appeals Specialist is responsible for evaluating and responding to QIO Appeals Requests, Health Plan Appeals Requests and denied claims dispute reconsiderations to ensure appropriate reimbursement and compliance with healthcare regulations. This role involves thorough review of clinical documentation, formulation of appeal letters, and collaboration with healthcare providers and payers to resolve denials effectively.

Assess denied (no prior authorization) claims dispute reconsiderations for identified agencies by reviewing medical records and determining medical necessity based on clinical review.  This team will not review records that have been denied due to administrative denials. Documents in tempo the clinical rationale for approving denied claims or sends for physician review and documents outcome, utilizing evidence-based guidelines and payer policies. Completes the QIO Appeals process to include requesting information from the agency, reviews documents for medical necessity, reviews NOMNC for validity, outreach to agency based on finding, completes DENC, uploads to the QIO portal, and follow-up for determination.  Work closely with physicians, case managers, and claims specialists to gather necessary information and support appeal processes. Process Health Plan appeals timely and according to company policies and procedures Process QIO Appeals timely and according to company policies and procedures Ensure all appeals are processed in accordance with federal, state, and payer-specific regulations and timelines. Procure and validate NOMNCs needed for appeals Create DENCs for all appeals timely and according to CMS and company policies and procedures Provide education to providers on NOMNC validity Maintain accurate records of all appeal and retro-review activities, decisions, and correspondence in tempo. Identify patterns in denials and provide feedback to relevant departments to mitigate future occurrences.