Clinical Appeals Specialist

5 days ago


Orange, California, United States Equiliem Full time

We are seeking a highly motivated and experienced Clinical Appeals Specialist to join our team at Equiliem Healthcare. This role involves participating in managing medical appeals and state hearing reviews for all lines of business, including handling expedited and standard requests.

The ideal candidate will ensure appeals and state hearing requests are processed in accordance with regulations, compliance standards, and policies and procedures. They will investigate and prepare case narratives and statements of position based on clinical information, benefits, and applicable regulations related to member or provider disputes of decisions.

As a Clinical Appeals Specialist, you will clearly articulate the facts and position regarding disputes to the Administrative Law Judge hearing the case. You will be responsible for creating and reviewing resolution letters for appropriateness of clinical criteria and regulatory requirements.

Key Responsibilities
  • Participate in program support, fostering a mission-driven culture of high-quality performance with a focus on customer service, consistency, dignity, and accountability.
  • Prepare clinical reviews based on clinical guidelines and monitor cases involving medical decisions and quality of care or service decisions.
  • Ensure all cases are completed in accordance with state and federal regulatory requirements, including timelines.
  • Presents recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.
  • Resolve complex and sensitive member issues within established timelines.
  • Maintain departmental database integrity by accurately entering case actions to assigned cases.
  • Analyze and report cases through GARS' subcommittee.
  • Oversee state hearing cases.
  • Discuss appeal process, medical decisions, and hearing rights with members, assisting them in coordinating services with providers and communicating status and outcome.
  • Assign position statements and represent at state hearings.

We offer competitive compensation for this role, with an estimated annual salary of $85,000-$110,000, depending on experience. Benefits include:

  • Medical Insurance
  • Vision & Dental insurance
  • Life Insurance
  • 401K
  • Commuter Benefits
  • Employee Discounts & Rewards
  • Payroll Payment Options


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