Healthcare Appeals Consultant

3 weeks ago


Durham, North Carolina, United States Lifelancer Full time

Our company, Lifelancer, is a leading talent-hiring platform in the Life Sciences, Pharma and IT domains. We connect talented professionals with opportunities in pharma, biotech, health sciences, healthtech, data science and IT.

We are currently seeking an experienced Healthcare Appeals Consultant to join our team. The successful candidate will be responsible for coordinating all aspects of appeals processes to ensure compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI, legislative, federal and NCQA requirements.

The estimated salary for this position is $65,000 - $90,000 per year, depending on experience and qualifications. This is a remote position that requires residing 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.

Responsibilities:
  • Provide clinical consultation with non-clinical staff within the Appeals Department.
  • 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.
Requirements:
  • Candidates need to have strong typing and MS Word skills.
  • 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.

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