PHRN and Medical Allied

Job Title: PHRN and Medical Allied Job Description We are seeking a highly skilled and detail-oriented Appeals PHRN Specialist to support our expanding Medicare line of business. The ideal candidate will have a strong background in Utilization Management (UM), appeals processing, and case validation, with hands-on experience in Medicare UM or Appeals. This role will be critical in ensuring high-quality clinical review, thorough case investigation, and timely resolution of appeal cases in accordance with CMS guidelines. Appeals Review & Case Handling: ○ Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols. ○ Conduct thorough case validation and clinical review using sound judgment and medical necessity criteria.…