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Clinical Appeals Analyst
4 months ago
Title: Clinical Appeals Analyst
Location: 4613 University Drive Durham NC 27707 United States (Onsite)
Duration: 6+ months
Pay rate: $41.75/hr (On W2)
Job Description:
The Clinical Appeals Consultant is responsible for supporting the increased workload in the Claims Department, particularly due to an increase in Behavioural Health claims. This role involves providing clinical consultation within the Appeals Department, managing the appeals process to ensure compliance with various criteria and requirements, and handling complex member and provider appeals. The ideal candidate will have experience with Behavioural Health claims and appeals processing.
Responsibility:
- 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.
- Analyse 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 BCBSNC 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.
- Licensure: Must be a Registered Nurse (RN) licensed in the state of North Carolina with a minimum of 3 years of clinical experience. Alternatively, candidates can be Licensed Practical Nurses (LPN), Physical Therapists (PT), or Occupational Therapists (OT) licensed in the state of North Carolina with at least 5 years of clinical experience.
- Clinical Experience: A minimum of 3 years of clinical experience for RNs or 5 years for LPNs, PTs, or OTs.
- Appeals Experience: Previous experience handling appeals is required, with a preference for those with Behavioural Health claims experience.
If this is a role that interests you and you’d like to learn more, click apply now and a recruiter will be in touch with you to discuss this great opportunity. We look forward to speaking with you
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