Clinical Appeals Analyst

Overview

• Provide clinical consultation and support within the Appeals Department, ensuring compliance with medical necessity criteria and regulatory requirements.
• Coordinate all aspects of the appeals process, including documentation collection and analysis of complex cases.
• Assist with Level 3 appeals and present findings to physician committees and leadership.
• Initiate claim adjustments and provide timely written documentation of case determinations.
• Identify trends and high-risk issues, recommending corrective actions to address future exposure.
• Educate internal employees on benefit misinterpretations and claim system errors.
• Handle member/provider inquiries and complaints professionally and efficiently.
• Coordinate with external vendors and provide requested information as needed.

Key Responsibilities & Duties

• Analyze member and provider appeals, reviewing contract provisions, legislation, and NCQA requirements.
• Ensure compliance with corporate medical policy and regulatory mandates.
• Present case analyses to physician committees and benefit administrators.
• Initiate corrective actions for appeals resulting from noncompliance issues.
• Develop action plans to address benefit misinterpretations and system errors.
• Provide professional responses to member/provider inquiries and complaints.
• Coordinate with external vendors to fulfill information requests.
• Identify trends and recommend solutions to mitigate future risks.

Job Requirements

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensed in North Carolina.
• Bachelor of Science in Nursing (BSN) or equivalent clinical qualification.
• Minimum of 3 years clinical experience; 5 years preferred.
• Knowledge of medical necessity criteria, corporate medical policy, and regulatory requirements.
• Strong analytical skills for complex case evaluation and documentation.
• Ability to handle member/provider inquiries professionally and efficiently.
• Experience in appeals coordination and compliance monitoring.
• Proficiency in creating corrective action plans and educating staff on benefit issues.