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Clinical Appeals Analyst

  • Location: Durham, 27707
  • Salary: $38 - $42 / hour
  • Job Type:Contract

Posted 3 months ago

Our client, a nationally recognized and award-winning company in the health insurance vertical, is seeking a Clinical Appeals Analyst for a contract opportunity.  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.   

Contract Duration: 6+ Months
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

Required Skills & Experience

  • LPN or RN and open to any specialty
  • Registered Nurse in the state of North Carolina or Compact License is acceptable
                   • 3-5 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.
  • Understanding policy, insurance background.

What You Will Be Doing

Daily Responsibilities

Responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company. Will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements.

  • 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.
  • 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.

****To be eligible to contract at this client you must be able to pass a drug test and criminal background check.