Clinical Appeals Nurse


Durham, North Carolina

a month ago

Similar Jobs
Clinical Appeals Nurse
Durham, North Carolina

a month ago

Job Description

Job Title: Clinical Appeals Analyst

Duration: 6 Months

Location- Remote position, can be local or in approved FTE states, must work EST zone

Out of state hiring will allow in North Carolina Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely. (Prefers NC candidates or possibly East Coast candidates only)

Training: Business Hours


  • Responsible for the analysis, research and completion of complex, Clinical Appeals Analyst:
  • Responsible for the analysis, research and completion of complex, non-routine appeals and grievances within the company.
  • Will address all customer concerns and ensure resolution and satisfaction. Ensure timeliness, quality and efficiency in all work to comply with mandated, legislative, North Carolina Department of Insurance (NCDOI) and National Committee for Quality Assurance (NCQA) and Federal requirements
  • Note: This job reports to Manager, Nursing or Team Leader, Medical only.

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.
  • 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's 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.

Required Skills: Registered Nurse in the state of North Carolina

  • 3-5 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:
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 if you require reasonable accommodation. 
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: $42.44/monthly.