Clinical Appeals Analyst (RN/LPN/PT/OT)
Location: Remote (Eligible in Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming)
Schedule: Monday-Friday, 8:00 AM - 5:00 PM
Employment Type: Full-Time (Contract; potential for conversion)
Job Summary
The Clinical Appeals Analyst provides clinical expertise and consultation to support the Appeals Department in reviewing and resolving complex member and provider appeals. This role ensures compliance with medical necessity criteria, corporate medical policies, regulatory guidelines, and contractual obligations while delivering accurate, timely, and high-quality case determinations.
Key Responsibilities
Provide clinical consultation and guidance to 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
State, federal, and NCQA requirements
Analyze complex and non-routine member and provider appeals and grievances (all lines of business excluding FEP)
Review and interpret clinical documentation, policies, and regulatory guidelines
Obtain and evaluate supporting documentation from external sources (e.g., providers, attorneys, pharmaceutical companies)
Present case findings and recommendations to physician committees, benefit administrators, and leadership as needed
Initiate claims adjustments when appropriate
Prepare and deliver clear, compliant written determinations to members, providers, and other stakeholders within required timelines
Identify trends, high-risk issues, and opportunities for process improvement
Recommend and implement corrective actions related to policy or compliance issues
Develop education plans to address internal knowledge gaps or claim processing errors
Respond professionally to member and provider inquiries via phone
Assist with Level 3 appeals and handle complaints/grievances as defined by federal regulations
Collaborate with external vendors and fulfill information requests as needed
Qualifications
Required
Active licensure in North Carolina as one of the following:
Registered Nurse (RN) with 3+ years of clinical experience
OR Licensed Practical Nurse (LPN), Physical Therapist (PT), or Occupational Therapist (OT) with 5+ years of clinical experience
Strong knowledge of clinical coverage criteria and ability to apply them to service requests
Experience with Medicare/Medicare Advantage
Ability to analyze complex clinical scenarios and make sound, independent decisions
What You'll Do in Your First 90 Days
Compensation
Salary Range: $70,000 - $80,000 with company subsidized medical, dental, and vision benefits