Clinical Reviewer, Medicare Clinical Quality

Job Summary
Responsible for reviewing & resolving Medicare complaints/appeals and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid (CMS) and internal clinical policy guidelines and leading the MCAG clinical staff as well as work directly with the Quality team on HEDIS measures,

Knowledge/Skills/Abilities

• Responsible for review, intervention and resolution of clinical complaints, appeals and grievances from Sonder members and related outside agencies, while maintaining confidentiality. May assist with non-clinical cases as needed
• Works directly with the Quality team on HEDIS measures supporting adherence and strategy to meet goals for measures
• Ensures all cases have been organized, categorized and documented thoroughly and correctly; Prioritizes and organizes tasks to meet compliance deadlines, assuring timeliness and appropriateness of responses in accordance with state, federal and Sonder Health Plans’ policies and procedures.
• Researches issues utilizing systems and clinical knowledge and approved "Decision Support Tools" in the decision-making process
• Collaborates with other clinical staff, Medical Directors and other team members as appropriate as well as works with other non-clinical staff as needed to help understand prescription drug complaints
• Analyzes work processes and identifies areas where procedures and quality could be improved
• Ability to meet established productivity, schedule adherence, and quality standards with reliably to meet work schedules and deadlines.
• Attends meetings as required; completes all necessary trainings
• Performs and assists in other duties and special projects as required
• Requires communicating directly (verbally and in writing) with members and providers to obtain relevant information and inform of decisions and next steps

Required Education

• RN - Will consider LPN with applicable experience/references

Required Experience

• Medicare Managed Care complaints, appeals and grievances or utilization management experience

• Excellent research skills
• Understanding of computer programs including but not limited to Microsoft Office and other related applications as well as ability to navigate CMS and state websites and systems as applicable
• Ability to work independently and collaboratively with cross-functional teams in a highly matrixed organization

Preferred Education/Experience

• Associates Degree in Nursing (ASN) or Bachelor of Science in Nursing (BSN) degree or higher
• Preferred completion of other healthcare related vocational programs/certifications (e.g., Certified Coder, billing)
• Preferred 2+ years’ experience working with Medicare Advantage requirements and Clinical Policies
• Preferred experience/participation in CMS and State Audits as well as experience with all levels

of the Medicare appeals process (ALJ, QIO, QIC)

• Preferred history with HEDIS measures