Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Clinical Appeals Analyst. 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.
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.
Contract Duration: 6 + Months
Required Skills & Experience:
- Candidates need to have strong typing and MS Word skills, and the ability to work under pressure in a high volume, high stress environment.
- Registered Nurse in the state of North Carolina with 3 years of clinical experience; OR
- Licensed Practical Nurse, Physical Therapist, or Occupational Therapist, licensed in the state of North Carolina with 5 years of clinical experience.
Desired Skills & Experience:
- Behavioral Health experience is helpful but not required.
What You Will Be Doing:
- 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.
- 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 needed.
To be eligible to contract at this client, you must be able to pass a drug test and criminal background check.
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