Clinical BP_2026

Job Title

Clinical BP_2026

Job Description

We are seeking a highly skilled and detail-oriented Appeals PHRN Specialist to support our expanding Medicare line of business. The ideal candidate will have a strong background in Utilization Management (UM), appeals processing, and case validation, with hands-on experience in Medicare UM or Appeals. This role will be critical in ensuring high-quality clinical review, thorough case investigation, and timely resolution of appeal cases in accordance with CMS guidelines.

Appeals Review & Case Handling

○ Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols.

○ Conduct thorough case validation and clinical review using sound judgment and medical necessity criteria.

Collaboration

○ Collaborate with onshore payer nurses and Independent Review Organizations (IROs) to collect and verify necessary documentation for appeal resolution.

○ Escalate complex cases as needed, providing detailed summaries and clinical insights.

Documentation & Communication

○ Provide clear documentation and clinical rationales for approval or denial decisions.

○ Maintain accurate records of all case activities and communicate findings effectively across teams.

Multitasking & Quality Assurance

○ Manage multiple appeal cases concurrently while maintaining high standards for quality and turnaround time.

○ Contribute to internal quality assurance reviews and support process improvement initiatives.

Compliance & Industry Standards

○ Stay current on CMS guidelines, UM criteria, and regulatory updates.

○ Ensure all appeals are resolved within required timelines and documented appropriately.

Technical Skills

Recommended Minimum Skills Requirements (MSRs)

○ Strong understanding of Medicare UM and Appeals processes.

○ Familiarity with CMS guidelines, InterQual/MCG criteria, and clinical review standards.

○ Proficiency in using clinical platforms, documentation systems, and Microsoft Office Suite (Word, Excel, Outlook).

Soft Skills

○ Strong case investigation, validation, and critical thinking abilities.

○ Excellent written and verbal communication skills in English.

○ High attention to detail, empathy, and sound clinical judgment.

Operational And Communication Skills

○ Ability to manage multiple cases and meet CMS-mandated turnaround times.

○ Strong organizational, documentation, and time management skills.

○ Comfort working with cross-functional teams including payer nurses and IROs.