Role Title: Clinical Appeals Specialist (PHRN) - Work From Home
ECLARO: A quick Summary ECLARO is an award-winning professional services firm headquartered in New York City and operating in the U.S., Canada, UK, Ireland, Australia and the Philippines. We are dedicated to a singular purpose: providing the Right People to meet every client's needs and solve business challenges through strategic staffing, permanent placement, custom outsourcing & offshoring. Utilizing our proprietary TRINIT-E Service Maturity Model, we help clients implement programs to promote innovation, automation and process improvement.
Job Summary: The clinical appeals specialist (PHRN) is responsible for the review, processing, and resolution of appeals cases in compliance with NCQA and, if applicable, CMS regulatory standards and client specific guideline. The role ensures timely and clinically sound appeal determination, upholding member rights and health plan obligations under commercial and CMS regulations. The clinical appeals specialist also supports case documentation, member and provider communications, and contributes to the quality and compliance targets of the payor program.
Essential Duties and Responsibilities:- ApplyInterQualorMCG (Milliman Care Guidelines)to determine the medical necessity of requested services.
- Coordinate with healthcare providers to ensure clinical documentation supports the level of care.
- Maintain high accuracy and productivity standards in a remote, fast-paced environment.
Minimum Hiring Qualifications:- Education:Graduate of BS Nursing.
- License:Must possess an activePHRNLicense.
- CPO Experience:At least1 yearof solid experience inInterQualorMCG (Milliman Care Guidelines).
- Clinical Experience:At least2 yearsof bedside experience in high-acuity areas:
- ICU(Intensive Care Unit)
- CCU(Critical Care Unit)
- ER(Emergency Room)
- Tech Requirements:Must have a stable internet connection and a conducive home office setup for aPermanent WFHarrangement.
If you are passionate about providing top-notch customer service and are eager to grow in the financial services industry, we encourage you to apply!
