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Clinical Analyst

1 month ago

Nashville, United States Robert Half Full time

A prestigious healthcare organization is seeking for a talented RN Clinical Denials Analyst to join their organization on a remote basis. The RN Clinical Denials Analyst will be working on Medicare Advantage cases and will be responsible for reviewing medical records to ensure medical necessity for members. The RN Clinical Denials Analyst will work closely with providers on discrepancies and educating on findings. Additional responsibilities are below:


  • Over 2 years of utilization review and denials experience with Medicare Advantage members
  • In charge of coordinating healthcare services with physicians, facilities, contracted providers, allied health professionals, funding sources and other community resources.
  • Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards
  • Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request
  • Ensures the denial reason is in the appropriate grade level and is easily understandable
  • Accountable for prospective reviews to evaluate denial requests, explore alternative treatments, and craft consistent denial language based on nationally recognized UM criteria such as Local Coverage Determinations (LCD), National Coverage Determinations (NCD), Milliman, and InterQual.
  • Responsible for establishing and maintaining effective working relationships with physicians and office staff, and effectively communicates with health plans, physicians, hospitals, extended care facilities, patients, and families.
  • Registered Nurse (RN) is required