Clinical Appeals Analyst

Overview

Employer Industry: Healthcare Services

Why consider this job opportunity:

• Work remotely from anywhere within the 28 allowed states
• Competitive pay for qualified candidates
• Opportunity for career advancement and growth within the organization
• Supportive and collaborative work environment
• Chance to make a positive impact on member experiences and healthcare outcomes

• 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 and corporate policies
• Analyze complex member and provider appeals and grievances across all lines of business
• Identify appropriate documentation collection from various external sources
• Provide written documentation of case determinations to appellants and involved parties in a timely manner

• Registered Nurse licensed in the state of North Carolina
• Minimum of 3 years of clinical experience
• OR Licensed Practical Nurse, Physical Therapist, or Occupational Therapist licensed in North Carolina with 5 years of clinical experience
• Strong analytical skills to review complex appeals and grievances
• Excellent communication skills for professional interaction with members and providers

• Experience in appeals or grievance processes within a healthcare setting
• Familiarity with NCQA requirements and corporate medical policies
• Ability to work collaboratively with a diverse team
• Strong organizational skills to manage multiple cases effectively

#Healthcare Services #Remote Work #Clinical Consultation #Career Opportunity #Equal Opportunity Employer

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We are not the EOR (Employer of Record) for this position. Our role in this specific opportunity is to connect outstanding candidates with a top-tier employer.