SPECTRAFORCE · 1 day ago
Clinical Appeals Analyst
United States
Full-time
Remote
Mid Level
3+ years expSPECTRAFOR is seeking a Clinical Appeals Analyst to provide clinical consultation and coordinate the appeals process. The role involves analyzing complex appeals, ensuring compliance with medical policies, and educating internal staff on benefit interpretations.
ConsultingCRMInformation TechnologyLegal
Hiring Manager
Kalpalata Deb
Responsibilities
Provide clinical consultation with nonclinical 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 client 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 requested
Qualification
Required
Registered Nurse in the state of North Carolina
3 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
Nursing experience
Medicare/advantage experience
Knowledge base of clinical coverage criteria and applying them to the request for services
Nursing license
Preferred
Comfort in making decisions (work in the gray)
Care radius
Worked in utilization management(any experience)
3-5 years
Company
SPECTRAFORCE
Welcome to SPECTRAFORCE, your gateway to NEWJOBPHORIA™! Established in 2004, SPECTRAFORCE is now one of the largest and fastest growing U.S.
1001-5000 employees
Funding
Current Stage
Late StageCompany data provided by crunchbase