Title: Clinical Appeals Analyst Duration: 6+ Months (This is a temp position, but the team will always be open to a potential conversion if the HC becomes available.) Location:The role is 100% remote, but candidates need to be from an approved conversion State list: (Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.) Shift Timing: M-F 8am - 5pm
Job Description:
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.
Hiring Requirements:
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.
Top 3-4 Required Skills:
Nursing experience
Medicare/advantage experience
Knowledge base of clinical coverage criteria and applying them to the request for services.
Nice to have Skills:
Comfort in making decisions (work in the gray).
Care radius.
Worked in utilization management(any experience).
Years of Experience:
3-5 years.
Education/Certifications Required:
Nursing license.
Breakdown of Duties/Typical Day:
Review cases that are needing more of a nursing/clinical review.
Monday/Friday are the heaviest day of the week.
Expedited 72 hours turn time for casework standard 32 day turn time.
Do you have screening questions?
Tell us about your experience with clinical coverage criteria?
Applicant Notices & Disclaimers
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 38.20/hr.
