Clinical Appeals Intake and Review Coordinator, RN

Job not on LinkedIn

🕒 September 21

🇺🇸 United States – Remote

💵 $70k - $90k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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The Phia Group, LLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2000

💼 Consulting

🏥 Healthcare

🛡️ Insurance

💰 Private Equity Round on 2018-09

Consulting • Healthcare • Insurance

The Phia Group, LLC is a dedicated provider of healthcare cost containment solutions, focusing on empowering self-funded health plans to maximize benefits and minimize costs. Through a comprehensive suite of services, including subrogation and recovery, claims negotiation, and cost transparency initiatives, The Phia Group aims to help employers and families navigate the complexities of healthcare with advocacy and expertise. Their commitment to improving healthcare accessibility and affordability sets them apart in the industry.

📋 Description

• Support a culture consistent with The Phia Group's core values • Apply up-to-date documentation and guidelines when triaging appeals • Perform clinical intake and triage of complex appeals • Review appeal submissions and medical records to identify diagnoses, medical history, treatments and services at issue, medical necessity or experimental/investigational questions, and key clinical arguments and dates • Identify missing or incomplete clinical documentation and coordinate requests for additional records, policies, prior reviews, or utilization management materials • Prepare concise, objective clinical summaries and chronologies for appeal reviewers • Help determine when an appeal requires independent clinical review and identify the appropriate clinical specialty • Prepare and organize materials for independent clinical reviewers and IROs • Monitor clinical review activity and identify issues that could create appeal deadline risk • Assist appeal team members with complex medical terminology, treatment pathways, and clinical documentation • Collaborate with PGC, claims, and internal teams on broader provider or operational issues • Support continuous improvement of appeal clinical intake, documentation, and workflows • Assist in customizing and creating appeal directives • Conduct research related to claims, appeals, nationally recognized sources, products, and solutions • Identify tools and technologies needed to expand products and solutions • Track and monitor productivity and value of existing and future concepts • Perform other related responsibilities and special projects as assigned

🎯 Requirements

• LPN or RN required • Bachelor of Science in Nursing (BSN) preferred • Appeals experience preferred • Strong clinical background with experience reviewing and synthesizing medical records • Ability to identify relevant clinical issues within large or complex medical files • Strong written communication skills, including the ability to create clear, neutral clinical summaries • Strong organizational skills and ability to manage multiple matters with regulatory or contractual deadlines • Ability to work effectively across clinical, legal, operational, and client-facing teams • Experience with and working knowledge of health insurance, Medicare guidelines and various healthcare programs • Exceptionally professional written communication skills • Highly organized with attention to detail and the ability to multi-task • Ability to perform essential job functions unaided or with reasonable accommodation • Extensive computer work and ability to operate office equipment

🏖️ Benefits

• Exceptional benefits • Equal opportunity employment practices • Reasonable accommodation for qualified individuals with disabilities

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