Offer summary

Qualifications:

Registered Nurse with 3 years clinical experience OR, Licensed Practical Nurse/Physical Therapist/Occupational Therapist with 5 years experience, Strong typing and MS Word skills, Ability to work under pressure in high volume environments.

Key responsabilities:

Provide clinical consultation for appeals processing

Coordinate compliance aspects of the appeals process

Analyze complex member/provider appeals and grievances

Identify appropriate documentation from external sources

Present analysis, initiate claim adjustments, and provide written determinations

Job description

Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Clinical Appeals Analyst. They have over 4 million customers and 5,000+ employees dedicated to providing innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.

Location: ** While the position is Remote, work from home, you must reside in North Carolina or one of the following states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.

Contract Duration: 6 + Months

Required Skills Experience

Candidates need to have strong typing and MS Word skills. have the ability to work under pressure in a high volume, high stress environment.
Registered Nurse in the state of North Carolina, 3 years of clinical experience;
OR
Licensed Practical Nurse, Physical Therapist, Occupational Therapist, Licensed in the State of North Carolina and 5 years of clinical experience.

Desired Skills Experience

Behavioral Health experience is helpful but not required.

What You Will Be Doing

Provide clinical consultation with non-clinical staff within the Appeals Department.
Coordinate all aspects of the appeals process to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements, as applicable.
Assist with Level 3 appeals as required.
Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements.
Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc.
Present analysis and documentation to appropriate physician committee, benefit administrators and leadership, as necessary.
Initiate claim adjustments on individual cases when necessary.
Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation.
Identify trends and high-risk issues to make recommendations to address future exposure.
Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP.
Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors.
Answer member/provider questions via incoming telephone calls in a professional quality driven manner.
May handle complaints/grievances as defined by the federal government.
Coordinates with external vendors and provides requested information as requested.
To be eligible to contract at this client you must be able to pass a drug test and criminal background check

Lifelancer ( https://lifelancer.com ) is a talent-hiring platform in Life Sciences, Pharma and IT. The platform connects talent with opportunities in pharma, biotech, health sciences, healthtech, data science and IT domains.

Please use the below Lifelancer link for job application and quicker response.

https://lifelancer.com/jobs/view/8f7654d2ef989d5ec3e5db209a66b23b

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