Clinical Appeals Analyst

Job Title: Clinical Appeals Analyst
Duration: 6 Months 
Location: Remote (must be located in any one of the following states only: <style type="text/css">td { border: 1px solid rgba(204, 204, 204, 1) }br { }</style>Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, NC, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.)
Shift: 8 am to 5 pm (EST Time)

This role is heavily regulated and the expectation is to support 15 to 20 cases a week and close them within 25 days.

Insurance and Care Radius experience is a plus.

Interview will be a 2 person panel interview via Zoom or Teams.

Training is 8 weeks and resources need to be focused in a distraction free environment.
 

Job Description:

• Provide clinical consultation with non-clinical 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 company 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
• RN in the state of North Carolina or any of the mentioned states with Compact License;

• 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.

 

About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com
 
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.
 
California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com.
 
LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer. 


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: $42.43/hr.