Job Description
About Judi Health Judi Health is an enterprise health technology company providing a comprehensive suite of solutions for employers and health plans, including: Capital Rx , a public benefit corporation delivering full-service pharmacy benefit management (PBM) solutions to self-insured employers, Judi Health ™ , which offers full-service health benefit management solutions to employers, TPAs, and health plans, and Judi® , the industry’s leading proprietary Enterprise Health Platform (EHP), which consolidates all claim administration-related workflows in one scalable, secure platform. Together with our clients, we’re rebuilding trust in healthcare in the U.S. and deploying the infrastructure we need for the care we deserve. To learn more, visit www.judi.health . Position Summary: Responsible for reviewing clinical coverage determination and appeals for different lines of business such as Commercial and Medicare. Knowledgeable in all aspects of coverage determination and appeals process and assist in meeting client expectations regarding efficiency and quality decision making. Position Responsibilities: Evaluate and review all appeals requests to render coverage determinations based on clinical criteria and medical necessity. Performs and handles inbound and outbound phone calls with physicians, healthcare providers and/or patients to facilitate appeal requests, answer inquiries, and resolve escalations. Collaborate with internal and external Medical Directors by providing appropriate clinical/medical data needed to perform clinical reviews per the health plan criteria. Interpret clinical guideline criteria and appropriately utilize clinical knowledge and resources when rendering approvals and denials on all levels of appeals. Perform peer to peer reviews with providers when requested. Perform scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to providers. Provide detailed and thorough
