CLINICAL APPEALS REVIEWER SKILLS, EXPERIENCE, AND JOB REQUIREMENTS

The Clinical Appeals Reviewer is responsible for analyzing and evaluating medical information, applying clinical review guidelines, and making informed clinical determinations. This role demands exceptional written and oral communication skills to effectively write rationales for appeal determinations and verbally present case summaries. The position requires proficiency in Microsoft Office applications, HIPAA rules, medical record coding, and virtual meeting tools, ensuring efficient multitasking in a fast-paced environment.

Essential Hard and Soft Skills for a Standout Clinical Appeals Reviewer Resume
  • Medical Coding
  • Clinical Documentation
  • Knowledge of Healthcare Regulations
  • Data Analysis
  • Understanding of Insurance Policies
  • Proficiency in Health Information Systems
  • Medical Terminology
  • Billing Procedures
  • Legal Compliance
  • Research Skills
  • Attention to Detail
  • Critical Thinking
  • Communication Skills
  • Problem-Solving
  • Negotiation Skills
  • Empathy
  • Time Management
  • Adaptability
  • Teamwork
  • Stress Management

Summary of Clinical Appeals Reviewer Knowledge and Qualifications on Resume

1. BS in Health Information Management with 3 years of Experience

  • Experience working in telephonic customer service
  • Ability to keep all company-sensitive documents secure
  • Working experience with ECAA, Adhoc, iCare, and Client Letter
  • Intake working experience
  • Proven experience working on Appeals
  • Excellent critical thinking skills, presentation skills
  • The ability to communicate and exchange information
  • Ability to comprehend and interpret documents and data
  • Have proficiency with Microsoft Word, Excel and PowerPoint.
  • Must live in a location that can receive a UnitedHealth Group-approved high-speed internet connection or leverage an existing high-speed internet service

2. BS in Nursing with 5 years of Experience

  • Registered Nurse (RN) or Master- level Behavioral Health Professional to practice at the independent practice level with current license in good standing in state of operations.
  • Clinical experience includes implementing or administering managed care or quality assurance activities.
  • Knowledge and understanding of state and federal guidelines and regulations.
  • Strong written and verbal communication skills and facilitating skills.
  • Interpersonal skills to interface with internal and external customers, including representatives of the Department of Insurance and government agencies in a rapport-developing manner.
  • Excellent organizational skills with highly detail-oriented.
  • Bilingual in English and Spanish.
  • Experience in processing appeals, denials, or grievances following regulatory or accreditation requirements.
  • Working experience in Utilization Management or audit.

3. BS in Healthcare Administration with 3 years of Experience

  • Current and unrestricted Registered Nurse licensure within the national footprint.
  • Working experience in a related clinical setting.
  • A good working knowledge of Interqual criteria.
  • Proficiency in working in a Windows 10 environment and utilizing MS Office including Word, Excel, and Outlook.
  • Proficiency utilizing Electronic Medical Records (EMRs).
  • Familiarity with the appeals and grievances process, preferably within a managed care organization.
  • Strong verbal and written communication skills
  • Solid critical thinking skills, presentation skills
  • The ability to manage and complete multiple high-priority tasks within the designated timeframe.

4. BS in Medical Coding and Billing with 4 years of Experience

  • Ability to analyze and evaluate medical information and to apply clinical review guidelines or judgment to make clinical determinations.
  • Excellent written communication skills including the ability to write clear, concise, accurate, and fact-based rationales in support of appeal determinations.
  • Excellent oral communication skills with particular emphasis on verbally presenting case summaries and decisions.
  • The ability to work in a production environment.
  • Ability to work proficiently with Microsoft Word, Excel and PowerPoint.
  • Working knowledge of HIPAA Privacy and Security Rules.
  • Ability to multi-task in a fast-paced working environment.
  • Demonstrated proficiency in virtual meeting tools i.e., Microsoft Teams, Zoom, etc.
  • Proficiency in medical record coding and ICD-10-CM and ICD-10-PCS coding methodologies, code sequencing, and discharge disposition following CMS requirements, Official Guidelines for Coding and Reporting, and Coding Clinic guidance.
Relevant Information
Clinic Assistant Skills, Experience, and Job Requirements