Opportunity Description
Job Title:Clinical BP_2026Job DescriptionWe 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 neede...