State Licensed Clinical Appeals Analyst

Job Summary

A company is looking for a Clinical Appeals Analyst who will manage claim denials and appeals related to hospital claims.

Key Responsibilities

• Review and appeal clinical level denials, including those related to medical necessity and authorization issues
• Audit medical records and prepare appeal correspondence while utilizing online payor portals
• Monitor and coordinate denial resolution efforts with payers and communicate issues professionally

Required Qualifications

• Licensed as an RN or LPN with a current state nursing license
• At least 3 years of experience as a Case Manager or equivalent is desired
• At least 1 year of experience with medical necessity appeals is preferred
• Bachelor's degree is desirable, but equivalent job experience will be considered
• Experience using standardized clinical guidelines, with InterQual experience preferred