Clinical Appeals Analyst
Durham, NC
100% Remote
Contract
$35/hr - $40/hr
Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Clinical Appeals Analyst. They have over 4 million customers and 5,000+ employees dedicated to providing innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.
Location: ** While the position is Remote, work from home, you must reside in North Carolina or one of the following states: 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.
Contract Duration: 6 + Months
Required Skills & Experience
What You Will Be Doing
Location: ** While the position is Remote, work from home, you must reside in North Carolina or one of the following states: 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.
Contract Duration: 6 + Months
Required Skills & Experience
- Candidates need to have strong typing and MS Word skills. have the ability to work under pressure in a high volume, high stress environment.
- 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.
- Behavioral Health experience is helpful but not required.
What You Will Be Doing
- 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 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.
****To be eligible to contract at this client you must be able to pass a drug test and criminal background check
You will receive the following benefits:
- Medical Insurance - Four medical plans to choose from for you and your family
- Dental & Orthodontia Benefits
- Vision Benefits
- Health Savings Account (HSA)
- Health and Dependent Care Flexible Spending Accounts
- Voluntary Life Insurance, Long-Term & Short-Term Disability Insurance
- Hospital Indemnity Insurance
- 401(k) including match with pre and post-tax options
- Paid Sick Time Leave
- Legal and Identity Protection Plans
- Pre-tax Commuter Benefit
- 529 College Saver Plan
Motion Recruitment Partners (MRP) is an Equal Opportunity Employer, including Veterans/Disability/Women. All applicants must be currently authorized to work on a full-time basis in the country for which they are applying, and no sponsorship is currently available. Employment is subject to the successful completion of a pre-employment screening. Accommodation will be provided in all parts of the hiring process as required under MRP’s Employment Accommodation policy. Applicants need to make their needs known in advance.