North Carolina Licensed Clinical Appeals Analyst

Job Summary

Providing clinical expertise and consultation, the full-time North Carolina Licensed Clinical Appeals Analyst will support the Appeals Department in reviewing and resolving complex member and provider appeals while working remotely.

Key Responsibilities

• Provide clinical consultation and guidance to non-clinical staff within the Appeals Department
• Analyze complex member and provider appeals, ensuring compliance with medical necessity criteria and regulatory guidelines
• Prepare and deliver clear, compliant written determinations to stakeholders within required timelines

Required Qualifications

• Active licensure in North Carolina as an RN with 3+ years of clinical experience, or LPN, PT, or OT with 5+ years of clinical experience
• Strong knowledge of clinical coverage criteria and experience with Medicare/Medicare Advantage
• Ability to analyze complex clinical scenarios and make sound, independent decisions