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?

 
 
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.