Clinical Appeals Reviewer Resume Samples

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E Huels

Enrique

Huels

2718 Zieme Cape

Boston

+1 (555) 664 8632

2718 Zieme Cape

Boston

Phone

p +1 (555) 664 8632

Experience Experience

Philadelphia, PA

Clinical Appeals Reviewer

Philadelphia, PA

Weber Group

Philadelphia, PA

Clinical Appeals Reviewer

Work with hospitals, clinics, facilities and the clinical team to manage request for services from members and/or providers
Retrieve work received from Care Advocacy via system work list
Work on high level tasks under management supervision/guidance
Some work is completed without established procedures
Work is frequently completed without established procedures
Initiate outbound contact to members or providers
Operate with high attention to detail when performing various data entry tasks

San Francisco, CA

Telephonic Clinical Appeals Reviewer

San Francisco, CA

Lindgren-Larkin

San Francisco, CA

Telephonic Clinical Appeals Reviewer

Provide Consulting/Education on Caller Issues/Trends as pertains to Appeals and grievances
Participate in special projects, work groups or committees as assigned
Provide Consulting / Education on Caller Issues / Trends as pertains to Appeals and grievances
Research complex issues across multiple databases and work with support resources to resolve inquiry
Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow-up with the member / provider / facility
Manage calls efficiently and effectively
Refax letters to providers and facilities, as necessary

present

Phoenix, AZ

Senior Clinical Appeals Reviewer

Phoenix, AZ

Wintheiser Group

present

Phoenix, AZ

Senior Clinical Appeals Reviewer

present

Work on high level tasks under management supervision / guidance
Retrieve work received from Care Advocacy via system worklist
Plan, prioritize, organize and complete work to meet assigned deadlines
Works independently
Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral Health, Medical claims / appeal management processes
Participates in workgroups or committees as requested
Work independently

Education Education

Bachelor’s Degree in Associates

University of Georgia

Bachelor’s Degree in Associates

Skills Skills

Strong attention to detail and maintaining quality focus
Strong time management and attention to detail
Strong attention to detail
Strong communication skills
Ability to handle a fast pace, deadlines, and competing priorities
Effective interpersonal skills, flexibility and ability to handle change
Ability to work independently as well as a member of the team
Strong time management skills
Demonstrated experience utilizing communication skills both verbal and written in a professional setting
Quality focused

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Senior Clinical Appeals Reviewer Multiple Locations Resume Examples & Samples

Mentor others
*Position can be located in: Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, or San Francisco, CA***
2+ years of Healthcare Insurance experience
1+ year of professional Appeals experience
Previous experience working with Microsoft Office Products
Bachelor's Degree or Higher
Experience in a professional Leadership role

Senior Clinical Appeals Reviewer Resume Examples & Samples

Retrieve work received from Care Advocacy via system worklist
Prioritize work based on due date and run applicable work list reports to monitor workload
Ensure correct letter template is utilized
Complete template with appropriate information and rationale
Select correct attachment and/or enclosure(s) and add to template
Process mail/correspondence received for retrospective reviews
Demonstrates a depth and breadth of knowledge/skills in own area and is often able to apply these outside of own function
Applies knowledge/skills to complex or escalated activities
Solves complex problems on own; proactively identifies new solutions to problems
Anticipates customer needs and proactively identifies solutions
Mentors and trains others
Often acts as a technical resource to others in own function
Acts as a facilitator to resolve conflicts on team; seen as key team member on project teams spanning more than own function
Participates in workgroups or committees as requested
May act as support and cover responsibilities for managing supervisor as needed
6+ months of telephonic customer service experience
Previous experience with handling claims denials and customer escalations
Medical claims experience complaints, grievance or appeals

Clinical Appeals Reviewer Resume Examples & Samples

Triage requests into correct categories
Operate with high attention to detail when performing various data entry tasks
Select, update and send department specific attachments and/or enclosure(s)
Solve moderately complex problems individually or in a team setting
Work on high level tasks under management supervision/guidance
Adhere to state and federal guidelines with processing appeals
Handle high claims and appeal volume while using internal Claim, Health, Medical claims/appeal management processes
1+ year of experience with Windows applications, such as Microsoft Word and Outlook
2+ years of experience with Data Entry
Previous experience working in a Healthcare environment (i.e. hospital, physician's office, pharmaceuticals or similar medical facilities)
Proficient with report generation, editing, filtering and updating reports using Excel
Experience working with Auto immune/ Primary immune conditions
Ability to Multi-task

Clinical Appeals Reviewer Resume Examples & Samples

Provide Phone Support to drive resolution of caller Questions/Issues
Develop and Maintain Productive Relationships/Interactions with Callers
Provide Consulting/Education on Caller Issues/Trends as pertains to Appeals and grievances
Resolve member service inquiries related to member and provider appeals and grievances
Triage calls to determine call type and transfer to the appropriate department as necessary
Refax letters to providers and facilities, as necessary
Ensure accurate documentation of calls
Identify requests for escalation/complaints and escalate accordingly
Route identified issues to the appropriate site, as necessary
Manage calls efficiently and effectively
Able to work Monday - Friday 8:00am - 5:00pm PST, No weekends or holidays. OT is available when business need requires it
College degree of Associates or Higher

Clinical Appeals Reviewer Resume Examples & Samples

Document request as A&G Correspondence or A&G Appeal
Determine if appeal is clinical or administrative and ensure correct letter template is utilized
Send out written notification as indicated under appeals policies compile IRO packets
Handle high claims and appeal volume while using internal Claim, UM/UR Behavioral Health, Medical claims/appeal management processes
*This position is located in the San Francisco Office and is NOT a telecommute role***
1 + year of Medical/Behavioral Health Appeal & Grievance experience
6 + months of Claim UR, and UM experience
Experience with ISET, IQ and/or UMR is highly desired
Medical Claims experience
Must have exceptional multi-tasking skills with the ability to prioritize tasks
Ability to handle a fast pace, deadlines, and competing priorities
Effective interpersonal skills, flexibility and ability to handle change
Excellent verbal, written, computation and organizational skills required

Clinical Appeals Reviewer Resume Examples & Samples

Provide phone support to drive resolution of caller questions/issues
Maintain a professional demeanor while referring individuals and families in behavioral health services to an Ombuds
Demonstrate use of professional terminology related to complaint, grievance and appeals
Track caller issues and trends, analyze patterns
Process telephone inquiries regarding basic consumer rights, appeals, appeal status, general processes, and urgent appeals
Ensure accurate documentation of all forms of communications received by individuals in services, behavioral health providers, state officials and others
Analyze and communicate issues, implications and decisions with appropriate parties
Demonstrates a detailed knowledge/skill in the assigned unit and have the ability to apply professional expertise outside of the unit
Applies knowledge/skills to resolve complex or escalated issues
Owns the question or issue through to resolution on behalf of the individual, family, provider or community member in a timely manner
Identify requests for escalation and escalate accordingly
Solves complex problems while proactively identifying new solutions to resolve the problem
Anticipates the needs of behavioral health consumers and providers and identifies solutions
Act as a technical resource/subject matter expert for other team members, if needed
Participates in workgroups and committees, as requested
Uphold a team lead persona and professional traits when supporting and participating in project teams that may span over more than one’s own job function
Acts as a resource for others
Experience in training/teaching skills to others
Comfort with public speaking
Quality focused
Exceptional multi-tasking skills with the ability to prioritize tasks
Ability to handle a fast pace and deadlines in a cubicle environment
Strong time management and attention to detail
Excellent conflict management skills
Experience using a computer and Microsoft Office (Word, Outlook, and Excel)
2+ years of lived or professional experience in a behavioral health setting
Bachelor’s degree in a Behavioral Health field
Certificate in Conflict Resolution
Certification in Project Management
Experience with Appeals and Grievances

Telephonic Clinical Appeals Reviewer Resume Examples & Samples

Familiar with Business/Industry concepts and terminology as pertains to appeals and grievances
Process telephone inquiries regarding: Basic appeal rights, Appeals status, General process, Basic complaints, Urgent appeals
Own problem through to resolution on behalf of the member /provider/facility in real time or through comprehensive and timely follow-up with the member/provider/facility
Research complex issues across multiple databases and work with support resources to resolve inquiry
Participate in special projects, work groups or committees as assigned
Able to work Monday - Friday 7:00am - 6:00pm CST, No weekends or holidays. OT is available when business need requires it
1+ years of Telephonic Customer Service experience
1+ years of Healthcare Insurance experience
Experience with Claims
Demonstrated experience utilizing communication skills both verbal and written in a professional setting

Telephonic Clinical Appeals Reviewer Resume Examples & Samples

Comfortable working Monday- Friday between hours of 7am-7pm CST in other locations, OT possible
Experience using a computer and Microsoft Office (MS Word, MS Excel, and MS Outlook)
Must live in or near Maryland Heights, MO, Atlanta, GA

Senior Clinical Appeals Reviewer Resume Examples & Samples

*Position can be located in: Atlanta, GA; St. Louis, MO; San Francisco, CA***
1+ years of experience utilizing Windows applications and Microsoft Office in a professional setting
1+ years of experience utilizing Medical Terminology in a professional setting
Must live in or near St. Louis, MO- Atlanta, GA - San Francisco, CA
Previous experience with handling Claims Denials and Customer Escalations

Clinical Appeals Reviewer Resume Examples & Samples

*Must Live in Atlanta, GA, St Louis, Philadelphia, PA , Schaumburg, IL***
1+ years of Medical/Behavioral Health Appeal & Grievance experience
Must Live in Atlanta, GA, St Louis, Philadelphia, PA , Schaumburg, IL
6+ months of Claim UR, and UM experience

Senior Clinical Appeals Reviewer Resume Examples & Samples

Extensive work experience, possibly in multiple functions
Act as a resource for others
Coordinate others' activities
2+ years of Telephonic Customer Service experience
Must live in or around Atlanta, GA, Chicago, IL, Philadelphia, PA, St. Louis, MO, or San Francisco, CA

Clinical Appeals Reviewer Resume Examples & Samples

Pull medical cases from a queue
Research these medical cases and create write up summaries
Pass medical case write up summaries on to nurses
Receive decisions on whether a case is approved or denied
Relay information to the members and document your work
Must have the ability to work Monday-Friday 6:00am-6:00pm
1+ year of Data Entry experience
1+ year of experience using a phone and computer simultaneously to perform the job duties
1 + year of experience working with Insurance Clinical Appeals
Insurance Claims experience
Experience with M&I platform
ISET, ICUE, CareOne, Facets, ETS systems experience

Clinical Appeals Reviewer Resume Examples & Samples

Retrieve work received from Care Advocacy via system work list
Document request in A&G denial note
Ensure accurate data entry
Plans, prioritize, organize and complete work to meet established and required time frames
Send out completed written notification as indicated under applicable department policies
Participates in workgroups and committees as requested
Solves moderately complex problems idependently
Works with team to solve complex problems
This is an office position**
Must live in or near St Louis, MO, Atlanta, GA, Schaumburg, IL, or Philadelphia, PA
Any college experience
Demonstrated experience utilizing communication skills, both verbal and written, in a professional setting
Multi-tasking and time management skills with the ability to prioritize tasks
Ability to work in a fast-paced and adapt well in an evolving environment
Strong attention to detail and maintaining quality focus

Clinical Appeals Reviewer Resume Examples & Samples

Plans, prioritize, organize and complete work to meet established and required timeframes
Solves moderately complex problems on own
Data Entry Skills
Experience with ISET, IQ and/or UMR
Demonstrate personal resilience

Clinical Appeals Reviewer Resume Examples & Samples

Solves moderately complex problems independently
1+ year of healthcare insurance experience
6+ months of data entry experience
Must live in St. Louis, MO, Shaumberg, IL, Philadelphia, PA, San Francisco, CA, or Atlanta, GA
Experience with medical claims
Experience with ISEET, IQ and/or UM

Clinical Appeals Reviewer Resume Examples & Samples

Ensure complaint has been categorized correctly
Determine and confirm member eligibility and benefits
Obtain additional documentation required for case review
Place relevant documents into image repository
Initiate outbound contact to members or providers
Review case to determine if review by Clinician is required
Research and resolve written complaints submitted by consumers and physicians/providers
Render decision for non-clinical complaints using sound, fact-based decision making
Draft verbiage for use in outbound correspondence
Prioritize and organize tasks to meet compliance deadlines
Ability to meet established productivity, schedule adherence, and quality standards
Experience in HMO health plans a plus
Some work is completed without established procedures
2+ years of telephonic customer service experience
Knowledge of HMO and / or Claims
Available to work an 8 hour shift 5 days a week from 7:00 am 4:00 pm or 7:00 am - 3:30 pm
Bilingual fluency in English and Spanish
Experience with NICE, Resolution, ECAA, Adhoc, iCare, and Client Letter
Intake experience
Experience working on Appeals

Clinical Appeals Reviewer Resume Examples & Samples

Generally work is self-directed and not prescribed
Must be able to work 7:00 am - 4:00 pm MST or 6:00 am - 3:00 pm PST
1+ year of experience working with Microsoft Office and PDF conversion
Data entry experience entering large volumes of data into software systems
Must live in Central, Mountain or Pacific Time Zones
Some College (or higher)
Knowledge of ICD-10/CPT coding
Experience working in a Telecommute/Virtual environment

Clinical Appeals Reviewer Resume Examples & Samples

Select correct attachment and / or enclosure(s) and add to template
Process mail / correspondence received for retrospective reviews
Supervision / guidance is required for higher level tasks
1+ years of healthcare insurance experience
Must live in St. Louis, MO, Shaumberg, IL, or Philadelphia, PA
Experience with ISEET, IQ and / or UM

Clinical Appeals Reviewer Resume Examples & Samples

Assist the clinical staff with setting up documents for Appeals
Assigning cases to clinical team
Updating authorizations
Sending out PMG notices
1+ year of experience working in an Office setting
Work hours are Tuesday - Saturday during normal business hours, 8am - 5pm
Associate's Degree or Bachelor's Degree
Medical Assistant Certification/Diploma
Customer Service experience analyzing and solving customer problems
Experience with Medical Terminology and ICD-9/CPT coding
Appeals experience

Clinical Appeals Reviewer Resume Examples & Samples

1+ years of experience working with Microsoft Office and PDF conversion
Must live in Waterford, NY
Ability to work 9:00 am to 6:00 pm EST
Some College or higher
Knowledge of ICD-10 / CPT coding
Experience working in a Telecommute / Virtual environment

Clinical Appeals Reviewer Resume Examples & Samples

Document request as A & G Correspondence or A & G Appeal
Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral Health, Medical claims / appeal management processes
1+ years of Medical / Behavioral Health Appeal & Grievance experience
Must Live in one of the following areas: San Francisco, CA, Schaumburg, IL, Philadelphia, PA, St Louis, MO, or Atlanta, GA
Experience with ISET, IQ and / or UMR
Must have exceptional multi - tasking skills with the ability to prioritize tasks

Telephonic Clinical Appeals Reviewer Resume Examples & Samples

Provide Phone Support to drive resolution of caller Questions / Issues
Develop and Maintain Productive Relationships / Interactions with Callers
Familiar with Business / Industry concepts and terminology as pertains to appeals and grievances
Provide Consulting / Education on Caller Issues / Trends as pertains to Appeals and grievances
Identify requests for escalation / complaints and escalate accordingly
Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow-up with the member / provider / facility
Comfortable working Monday through Friday between hours of 7:00 am - 7:00 pm CST in other locations, OT possible

Clinical Appeals Reviewer Resume Examples & Samples

High School Diploma or GED or higher
Candidates must be able to create, edit, copy, send and save documents, correspondence and spreadsheets in MS Excel, MS PowerPoint, MS Word, MS Outlook
Must be available to work either 8:30am to 5:30pm or 9:00am to 6:00pm
Experience working with Auto immune / Primary immune conditions
1+ years experience with prior authorizations

Clinical Appeals Reviewer Resume Examples & Samples

Review Medical records for missing documentation and request missing documentation
Set up case with all relevant documents, Medical records and benefit documents
Responsible for managing appeal case load routed by the Senior Triage Specialist from the department Medical Management queue in the Escalation Tracking System (ETS) to the Triage Specialist's personal work queue in ETS
Ability to identify the correct type of appeal and re-route correspondence determined not appropriate for processing within the department
Appropriately and completely entering the appeal triage template into the Integrated Clinical User Experience (ICUE) and into ETS
Able to type at least 45-50 WPM accurately
Must be located within a 50-mile radius to a local office (This is a Telecommute position)
Experience working in a Clinical, Hospital or Medical Office setting
Knowledge of Medical Terminology and CPT/ICD-10 Coding
Managed Care/Health Insurance experience
Experience utilizing Macro Express or Macro Express Pro
UNET experience

Senior Clinical Appeals Reviewer Resume Examples & Samples

Plan, prioritize, organize and complete work to meet assigned deadlines
Select, update and send department specific attachments and / or enclosure(s)
Work on high level tasks under management supervision / guidance
1+ years of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Word, and Outlook
Strong Data Entry Skills
6+ months of Claim UM (Utilization Management) experience
Familiarity with Medical Terminology
Ability to work independently as well as a member of the team
Excellent verbal, written, computation and organizational skills

Clinical Appeals Reviewer Resume Examples & Samples

Research and resolve written complaints submitted by consumers and physicians / providers
Must be available to work an 8-hour shift, 5 days per week in core business hours
Experience with NICE, Resolution, ECAA, Ad hoc, iCare, and Client Letter

Clinical Appeals Reviewer Resume Examples & Samples

High School Diploma / GED (or higher)
1+ years of experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook
Strong Data Entry skills
Must live in one of the following areas: San Francisco, CA, Schaumburg, IL, Philadelphia, PA, St Louis, MO, or Atlanta, GA

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