Clinical Appeals Analyst

Overview

• Serve as a clinical expert within the Appeals Department, ensuring adherence to medical necessity criteria and regulatory standards.
• Coordinate the appeals process, including documentation review, case analysis, and resolution communication.
• Analyze complex appeals, providing detailed findings to physician committees and leadership teams.
• Initiate claim adjustments and deliver timely written determinations to stakeholders.
• Identify trends and high-risk issues, recommending proactive solutions to mitigate future risks.
• Educate team members on benefit interpretations and claim system functionalities.
• Handle inquiries and grievances professionally, ensuring member and provider satisfaction.
• Collaborate with external vendors to provide necessary information and ensure compliance.

Key Responsibilities & Duties

• Evaluate appeals and grievances for compliance with medical policies and NCQA standards.
• Gather and analyze documentation from providers and pharmaceutical companies.
• Present case analyses to physician committees and benefit administrators for review.
• Adjust claims and document determinations in accordance with legislative mandates.
• Address appeals arising from contractual noncompliance and recommend corrective actions.
• Develop educational initiatives to improve employee understanding of benefit provisions.
• Respond to inquiries and resolve complaints, ensuring professional communication standards.
• Collaborate with external vendors to ensure timely and accurate information exchange.

Job Requirements

• Active Registered Nurse license in North Carolina with a Bachelor of Science degree.
• Minimum of 3 years clinical experience; 5 years preferred for advanced expertise.
• Familiarity with Medicare/Advantage programs and utilization management processes.
• Proficiency in applying clinical coverage criteria to service requests.
• Strong decision-making skills and ability to navigate ambiguous situations effectively.
• Experience with Care Radius and similar tools is advantageous.
• Excellent analytical and communication skills for handling appeals and grievances.
• Capability to identify trends and propose actionable solutions for improvement.