Authorization Management Clinical Reviewer - Appeals and Denials

Authorization Management Clinical Reviewer – Appeals and Denials This job is responsible for reviewing acute and post-acute authorization requests and medical records to evaluate medical necessity using established clinical guidelines.

As a Denials and Appeals Clinical Reviewer, you will manage medical necessity denials from initial notification through final resolution. You will apply acute-care clinical knowledge, payer requirements, and medical necessity criteria to determine whether a denial should proceed to peer-to-peer review, reconsideration, formal appeal, or another appropriate resolution path.

The Clinical Reviewer collaborates with physicians, healthcare providers, and internal and external stakeholders to support appropriate levels of care and ensure medical necessity reviews are completed accurately, consistently, and in accordance with applicable regulatory and organizational requirements.