Clinical Appeals Specialist

4 weeks ago


Durham, North Carolina, United States Lifelancer Full time
Job Title: Clinical Appeals Analyst

Job Description:

Our client, a leading health insurance company, is seeking a Clinical Appeals Analyst to join their team. As a Clinical Appeals Analyst, you will play a critical role in ensuring that appeals are processed efficiently and effectively.

Responsibilities:

* Provide clinical consultation to 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
* 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

Requirements:

* 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:

* Behavioral Health experience is helpful but not required

What You Will Be Doing:

As a Clinical Appeals Analyst, you will be responsible for providing clinical consultation to non-clinical staff within the Appeals Department. You will also 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. Additionally, you will assist with Level 3 appeals as required and 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.

Why Work with Us:

Lifelancer is a talent-hiring platform in Life Sciences, Pharma and IT. We connect talent with opportunities in pharma, biotech, health sciences, healthtech, data science and IT domains. If you are interested in this role, please use the below Lifelancer link for job application and quicker response.

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