Clinical Appeals Reviewer Resume Sample

4.8
20 votes
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Judy Wisoky
97524 Glover Lane,  New York, NY
+1 (555) 735 1198

Work Experience


Senior Clinical Appeals Reviewer
06/2016 - PRESENT
Philadelphia, PA
  • This is an office position
  • Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow - up with the member / provider / facility
  • Provides expertise or general support in reviewing, researching, investigating, negotiating and resolving all types of appeals and grievances
  • Determine whether additional appeal or grievance reviews are required (e.g., medical necessity)
  • Work with claims or provider groups to clarify determinations and ensure appropriate handling
  • Collect and provide information to support appeal or grievance audits
  • Research and respond to customer or regulatory inquiries and/or second level reviews
  • Send cases to external consultant for review as appropriate
  • Manage case process from start to finish
Clinical Appeals Reviewer
02/2012 - 02/2016
Houston, TX
  • Analyzes and identifies trends for appeals and grievances
  • Communicate Appeal or Grievance Status or Resolution
  • Make Benefit or Administrative Appeal or Grievance Determinations
  • Utilize Computer Systems to Research, Track, Document and Communicate Appeal or Grievances
  • Select, update, and send department specific attachments and / or enclosure(s)
  • Confirms the Medical Director Review (MDR), Appeal, or Peer request was appropriately documented in the Referral Management System (RMS)
  • Ensures that the MDR request is not outside the required 72-hour time frame prior to processing in accordance with departmental policy and procedures
  • Processes and works to expedite all RUSH MDR, Appeals, and Peers at the direction of the Case Manager, Supervisor or Adjuster that do not fall outside the required product time frames
  • Ensures all reviews are scheduled with the appropriate provider / specialty in accordance with departmental policy and procedures
Senior Clinical Appeals Reviewer
06/2007 - 08/2011
New York, NY
  • Prepares and ensures the quality and content of the MDR, Appeal or Peer documentation sent are appropriate and concise to address the required timely review
  • Ensures the quality, content and timeliness of the final MDR, Appeal or Peer reports and determination letters
  • Maintains and updates MDR, Appeal and Peer contracted provider database
  • QA’s and approves each MDR, Appeal and Peer provider invoice / check request for payment which is issued by the Finance department
  • Maintains the integrity of the RMS system at all times and adheres to all electronic paperless workflows
  • Holds to the philosophy and standards of quality as outlined by Procura Management, Inc
  • Experience using a computer and Microsoft Office ( Word, Excel and Outlook) Word (create, edit, save) Excel (create, edit, sort, filter) Outlook (send , receive, set appointments)
  • Months of data entry experience

Education


University of Mount Union
2002 - 2007
Bachelor's Degree in Health

Professional Skills


  • Experience working in a Telecommuting/Virtual environment
  • Experience working with Insurance Clinical Appeals
  • Previous Data entry experience entering large volumes of data into software systems
  • ICD10, CPT and HCPCS coding experience
  • Experience complaints, grievance or appeals
  • Telephonic Customer Service experience in a call center environment
  • 6+ months of Medical / Behavioral Health Appeal & Grievance experience

How to write Clinical Appeals Reviewer Resume

Clinical Appeals Reviewer role is responsible for insurance, research, reporting, wireless, database, finance, software, health, education, coding.
To write great resume for clinical appeals reviewer job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Clinical Appeals Reviewer Resume

The section contact information is important in your clinical appeals reviewer resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

  • First and last name
  • Email
  • Telephone number

Work Experience in Your Clinical Appeals Reviewer Resume

The section work experience is an essential part of your clinical appeals reviewer resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous clinical appeals reviewer responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular clinical appeals reviewer position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Clinical Appeals Reviewer resume experience can include:

  • Medical claims processing experience or equivalent combination of education, experience and / or applicable military experience
  • Attention to detail, strong problem-solving and time-management skills
  • Work in a fast-paced environment, flexible and adaptable to changing situations, and a strong commitment to teamwork
  • Experience using a computer and Microsoft Office (Microsoft Word, Microsoft Excel, and Microsoft Outlook) to create, copy, edit, save and send
  • Experience working with Microsoft Office Word and PDF conversion (ability to convert documents)
  • Managed Care / Health Insurance experience

Education on a Clinical Appeals Reviewer Resume

Make sure to make education a priority on your clinical appeals reviewer resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your clinical appeals reviewer experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

  • School you graduated from
  • Major/ minor
  • Year of graduation
  • Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Clinical Appeals Reviewer Resume

When listing skills on your clinical appeals reviewer resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical clinical appeals reviewer skills:

  • Experience working with Microsoft Word and PDF conversion (ability to convert documents)
  • Any experience utilizing Macro Express or Macro Express Pro
  • Experience with E&I platform
  • Previous SCIIDRS, IDRS, ECAA,ETS, IQ, systems experience
  • Some college experience (or higher)
  • Medical / Behavioral Health Appeal and Grievance experience

List of Typical Skills For a Clinical Appeals Reviewer Resume

1

Skills For Telephonic Clinical Appeals Reviewer Resume

  • Experience with Word, Excel & Outlook. (Word - Create correspondence and work within templates. Excel - Data Entry, Sort / Filter, and work within tables. Outlook - email and calendar management.)
  • Experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel (create, copy, edit, send, save), Microsoft Word (create, copy, edit, send, save), and Microsoft Outlook (create, copy, edit, send, save)
  • Experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel (create, copy, edit, send, and save), Microsoft Word (create, copy, edit, send, and save), and Microsoft Outlook (create, copy, edit, send, and save)
  • Previous experience working with Microsoft Office including Microsoft Outlook (ability to create, edit, save, and send documents) and Microsoft Excel (ability to create, edit, save, and send documents)
  • Previous Member Appeals experience in a payor environment
  • College experience (or higher)
  • Experience and / or knowledge of NJ Auto Regulations
  • Working knowledge of Medical Terminology and ICD-10 / CPT coding
2

Skills For Senior Clinical Appeals Reviewer Resume

  • Knowledge of Medical Terminology and CPT / ICD-10 Coding
  • Experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel (create, copy, edit, send, and save), Microsoft Word (create, copy, edit, send, and save), and Microsoft Outlook (create, copy, edit, send, save)
  • Experience with MS Office Applications: Microsoft Word, Microsoft Excel and Microsoft Outlook (ability to create and edit documents/spreadsheets as well as send emails with attachments)
  • Customer service experience and / or experience in administrative function
  • Telephonic Customer Service
  • Experience using a computer and Microsoft Office: Microsoft Word, Microsoft Excel, and Microsoft Outlook (with the ability to create, edit, save and send documents and spreadsheets)
  • Previous experience working with Microsoft Office including: Microsoft Outlook (ability to create, edit, save, and send documents), Microsoft Word (ability to create, edit, save, and send documents), and Microsoft Excel (ability to create, edit, save, and send spreadsheets)
3

Skills For Senior Clinical Appeals Reviewer Multiple Locations Resume

  • Experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel (create, copy, edit, send, and save), Microsoft Word (create, copy, edit, send, and save), and Microsoft Outlook (create, copy, edit, send, save)
  • Medical / Behavioral Health Appeal and Grievance experience
  • Use a Windows PC, research on the internet, and learn new applications easily
  • Previous experience working with Microsoft Office including Microsoft Outlook (ability to create, edit, save and send documents) and Microsoft Excel (ability to create, edit, save, and send spreadsheets)
  • Able to type at least 45+ wpm accurately
4

Skills For Clinical Appeals Reviewer Resume

  • Experience with Word, Excel & Outlook. (Word – Create correspondence and work within templates. Excel – data entry, sort / filter, and work within tables. Outlook – email and calendar management.)
  • Experience with Microsoft: Word, Excel and Outlook. (Word - Create correspondence and work within templates. Excel - Data Entry, Sort / Filter, and work within tables. Outlook - email and calendar management.)
  • Proven skills to establish rapport, trust and confidence with internal departments, staff and external vendors
  • Strong experience and knowledge of Claims, Medicare / Medicaid guidelines
  • Understanding of claims processing guidelines
  • ICD-9, HCPCS / CPT coding, HCFA 1500’s & UB92’s
  • Proficient in Microsoft Office Suite including Word (create, edit, save), Excel (create, edit, save), and Outlook (send & receive emails)
5

Skills For Telephonic Clinical Appeals Reviewer Resume

  • Provide overarching support for the claims process and related activities for the World Trade Center Health Program Nationwide Provider Network
  • Provide analysis and reporting on claims level detail
  • Process daily / weekly claims error files to ensure efficient and expeditious handling of claims
  • Certified Medical Reimbursement Specialist (CMRS) exam completion
  • Remain calm in stressful situations and to conduct themselves in a professional manner at all times
  • Experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook with the ability to create, edit, save and send documents
6

Skills For Senior Clinical Appeals Reviewer Resume

  • Experience with an intermediate (or higher) level of proficiency with Windows applications, such as Microsoft Excel, Microsoft Word, and Microsoft Outlook with the ability to create, edit, save and send documentations
  • Develop and Maintain Productive Relationships /Interactions with Callers
  • Refax letters to providers and facilities, as necessary ensure accurate documentation of calls
  • Own problem through to resolution on behalf of the member / provider / facility in real time or through comprehensive and timely follow-up with the member /provider / facility
  • Secondary review of claims approval tasks within MedNet. Also includes, the maintenance of the pended claims file and claims with zero dollars
7

Skills For Senior Clinical Appeals Reviewer Multiple Locations Resume

  • Facilitate the code request process with LHI and the World Trade Center Health Program. Tracking of all codes submitted and the response rate of the Health Program
  • Maintenance of the World Trade Center Health Program code book within MedNet. Provide regular updates to the effected operational departments on new versions of the code book
  • Review and process Prior Authorization Level 3 documentation to the World Trade Center Health Program. Communicate decisions from the Health Program to the effected departments
  • Handle high claims and appeal volume while using internal Claim, UM / UR Behavioral
  • Health, Medical claims / appeal management processe

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