State Licensed Clinical Appeals Analyst

Job Summary

A company is looking for a Clinical Appeals Analyst to support a prominent organization within the health insurance industry.

Key Responsibilities

• Perform clinical reviews for member and provider appeals in compliance with regulatory standards
• Serve as a clinical resource for non-clinical appeals staff and collaborate with physicians and internal stakeholders
• Review and analyze complex medical documentation, draft written appeal determinations, and identify trends for improvement

Required Qualifications

• An active Registered Nurse (RN) license in their state of residence
• At least three years of clinical experience for RN applicants
• Experience working with Medicare and/or Medicare Advantage programs
• Background in telephonic appeals, case management, or utilization management
• Strong knowledge of medical policy interpretation and regulatory standards