Clinical Appeals Analyst

Overview

• Provide clinical consultation within the Appeals Department, ensuring compliance with medical necessity criteria and legislative requirements.
• Coordinate all aspects of the appeals process, including documentation collection and case analysis.
• Analyze complex member and provider appeals, presenting findings to physician committees and leadership.
• Initiate claim adjustments and provide timely written documentation of 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 professionally and resolve complaints/grievances as required.
• Coordinate with external vendors, providing requested information promptly.

Key Responsibilities & Duties

• Review appeals and grievances, ensuring compliance with Corporate Medical Policy and NCQA requirements.
• Collect and analyze documentation from external sources, including pharmaceutical companies and providers.
• Present case analyses to physician committees and benefit administrators.
• Adjust claims and document case determinations in compliance with mandates and legislation.
• Identify and address appeals resulting from noncompliance with contract provisions.
• Develop action plans to educate employees on benefit misinterpretations.
• Respond to member/provider inquiries and resolve complaints professionally.
• Collaborate with external vendors to provide required information.

Job Requirements

• Registered Nurse licensed in North Carolina with a Bachelor of Science degree.
• Minimum of 3 years clinical experience; 5 years preferred.
• Experience in Medicare/Advantage and utilization management is advantageous.
• Knowledge of clinical coverage criteria and their application to service requests.
• Comfort in decision-making and working in ambiguous situations.
• Proficiency in Care Radius and similar tools is beneficial.
• Strong analytical and communication skills for handling appeals and grievances.
• Ability to identify trends and recommend corrective actions effectively.