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Appeals Clinical Consultant
Point32Health. Serve as a key clinical resource for various aspects of Appeals & Grievances work .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Appeals & Grievances processes within managed care, with a strong clinical understanding of medical terminology and provider plans of care. Capable of analyzing trends and providing clinical input to support decision-making and case management.
Highest-signal resume keywords
Understanding Of Appeals & Grievances ProcessesClinical Knowledge Of Medical TerminologyAbility To Analyze Appeals And GrievancesExperience In Managed Care EnvironmentAbility To Collaborate Within A Team
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Input Within Scope Of PracticeAssessment Of Appeal And Grievance TrendsCase Preparation For Appeals CommitteesIdentification Of Complex MembersReferral To Case Management Programs
Soft Skills
Ability To Work IndependentlyCollaborative Teamwork
Industry Keywords
Managed CareCommercial PlansMedicaidAppealsGrievances
About the role
Key responsibilities & impact- Serve as a key clinical resource for various aspects of Appeals & Grievances work
- Support Analyst teams in developing knowledge of medical terminology and provider plans of care
- Analyze and assess cases and consult with Analysts regarding physician review
- Identify complex members and collaborate with Analysts to refer them to case management or disease management programs
- Assess appeal and grievance trends and help leadership develop messaging for internal stakeholders
- Consult with Analysts and MD reviewers on complex appeals and grievances
- Assist Analysts with case preparation and participate as a voting member in cross-functional Appeals Committees
- Provide clinical input within scope of practice for appeal decisions
- Assist with new-hire training on clinical aspects of Appeals & Grievances work
- Perform other duties and projects as assigned
Requirements
What you’ll need- Understanding of Appeals & Grievances processes, particularly in the managed care environment
- Focus on Commercial plans and Medicaid
- Clinical knowledge and ability to understand medical terminology and provider plans of care
- Ability to analyze and assess appeals and grievances
- Ability to work independently and collaboratively within a team environment
- Ability to identify complex members and refer them to case management or disease management programs
- Ability to assess appeal and grievance trends
- Ability to provide clinical input within scope of practice
- Credentials and experience appropriate to the role, as evaluated by the employer
Benefits
Comp & perks- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits to support career development, individual & family health, and financial health
- Variable pay eligibility