Clinical Reviewer

FIND YOUR FUTURE We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and commitment to diversity and inclusion. Overview The Clinical Reviewer will be responsible for the collection and review of medical records specific to quality complaints/grievances and appeals as indicated in support of a high performing health plan and physician network. The Clinical Reviewer will investigate quality complaints/grievances and appeals, document research of initial coverage determinations, and lead coordination of clinical review with appropriate internal stakeholders and Medical Director. This position will prepare written responses to appeals and complaints/grievances, establish plans of correction and provide education to members and providers. In addition, they will initiate ancillary department referrals in accordance with regulatory standards, clinical criteria, and member benefit contract. Qualifications Licensed NYS Registered Nurse required with active, unrestricted license; Bachelor of Science in Nursing preferred. Four (4) years of clinical experience required, Utilization Management experience preferred. Comprehensive knowledge and experience with managed care benefit plans. Ability to research and assist clinical team in rendering coverage determinations in accordance with established clinical guidelines and member contract. Excellent verbal, written and interpersonal communication skills required. Ability to handle escalated calls and to deliver messages clearly and articulately regarding decisions. Ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific clinical and claims platforms. Possess initiative, attention to detail, and solid, logical thinking capabilities. Proven ability to manage multiple, time-sensitive priorities and adherence to all deadlines, while remaining organized. Ability to work a flexible schedule required. Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable. Essential Accountabilities Research Thoroughly investigate clinical appeals, and complaints/grievances utilizing appropriate internal and external resources to ensure coverage determinations are consistent and within clinical guidelines and member benefit contract. Investigate and research all levels of quality complaints/grievances, appeals, concerns, plans of correction and contractual appeals that require MD decision making independently to ensure decisions are within accordance of applicable policies, procedures, criteria, and contracts. Research standards of care pertaining to medical issues in support of clinical care algorithms. Special projects as assigned. Compliance Ensure verbal and written responses to quality complaints/grievances, appeals and investigations follow regulatory standards. Responsible to create detailed summary of all findings and recommendations for MD review and provide direction and disposition for member complaints and internal concerns, facility and/or physician improvement opportunities. Responsible for providing member education/outreach related to coverage determinations and member benefit contract. Coordination Coordinate and collaborate with ancillary departments and peers within the clinical team in rendering consistent coverage determinations and claims payments in accordance with policy, criteria, and member benefit contract. Demonstrate positive interrelationships and service excellence in performance of duties by meeting or exceeding the expectations of internal and external service groups. Coordinate with external agencies to prepare case files when needed for external appeals. Reporting Thorough and accurate completion of log worksheet to maintain consistency in logging complaints/appeals. Responsible for maintaining and monitoring outstanding case logs to plan and prioritize workload. Monitor daily reports to ensure accuracy and timeliness of complaints/grievances and appeals. Responsible to identify appeal trends and process improvements where applicable. Continuous Improvement Based on measurement and evaluation of clinical appeal data, assist in continuously developing systems, workflows, and coverage criteria to better meet the needs of the customer. Departmental Support Responsible for assisting in meeting department goals and objectives and identifying process improvements to continuously improve member/provider satisfaction. Attend assigned meetings as department representative and report to team members when necessary. Immigration or work visa sponsorship will not be provided for this position Hiring Compensation Range: $37.25 - $40.00 hourly Compensation may vary based on factors including but not limited to skills, education, location and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future. As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here ( for additional EEO/AAP or Reasonable Accommodation information. Current Associates must apply internally via the Job Hub app. The Independent Health Family of Companies, headquartered in Buffalo, NY, serves nearly 400,000 members and provides innovative health care products and benefits designed to engage consumers in their health and well-being. Established in 1980, our comprehensive portfolio includes Pharmacy Benefit Dimensions, Reliance Rx, Nova Healthcare Administrators, Care for You and the Independent Health Foundation. Our culture sets us apart. Our core values drive who we are and the work we do. As a member of our family, you're part of something special, in your work and in the community. We understand and appreciate that everyone has unique experiences, perspectives and identities which is why we pledge to create a safe space where all people and ideas are welcomed. We are here to continue learning and to generate important dialog. We are committed to doing what matters most - reaching out, working together, and caring for our community. A healthy community benefits everyone who lives in it. You too can be part of making difference in the lives of others, together we achieve so much more. Please click here ( to view our Community Reports. Apply today and join us on the journey to a happier, healthier, and more inclusive community. We are a drug-free workplace. We are committed to providing reasonable accommodations for qualified individuals with disabilities and disabled veterans. An applicant for employment in need of an accommodation to participate in the application and recruitment process should contact Human Resources at: or Human Resources, 511 Farber Lakes Drive, Williamsville, NY 14221. Please note, we do not accept unsolicited resumes. We do not accept resumes from headhunters, placement agencies, or other suppliers that have not signed a formal agreement with us.

Created: 2024-10-29