Will “Clinical Appeals Reviewer” be Automated?

Core Skills & Abilities

• Review and evaluate data on documents, such as claim applications, birth or death certificates, or physician or employer records.

• Recommend the acceptance or rejection of claims or compromise settlements according to laws, regulations, policies, and precedent decisions.

• Determine existence and amount of liability according to current laws, administrative and judicial precedents, and available evidence.

• Research and analyze laws, regulations, policies, and precedent decisions to prepare for hearings and to determine conclusions.

• Explain to claimants how they can appeal rulings that go against them.

• Conduct hearings to review and decide claims regarding issues, such as social program eligibility, environmental protection, or enforcement of health and safety regulations.

• Conduct studies of appeals procedures in field agencies to ensure adherence to legal requirements and to facilitate determination of cases.

• Authorize payment of valid claims and determine method of payment.

• Schedule hearings.

• Rule on exceptions, motions, and admissibility of evidence.

• Confer with individuals or organizations involved in cases to obtain relevant information.

• Issue subpoenas and administer oaths in preparation for formal hearings.

• Prepare written opinions and decisions.

• Monitor and direct the activities of trials and hearings to ensure that they are conducted fairly and that courts administer justice while safeguarding the legal rights of all involved parties.