Clinical BP_2026

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 comple...