Tennessee Licensed Nurse Analyst

Job Summary

Working remotely on a full-time basis, the Tennessee Licensed Nurse Analyst will review and process appeals submitted by members and providers, ensuring compliance with CMS, Medicare, and TennCare guidelines while managing multiple priorities and turnaround times.

Key responsibilities

• Ensure timely and quality resolution of appeals and grievances per regulations and guidelines
• Evaluate medical necessity documentation and prepare case files for the Medical Director's review
• Collaborate with clinical and non-clinical staff to resolve appeals and quality of care cases effectively

Required qualifications

• Active Registered Nurse (RN) license in Tennessee or a participating state in the Nurse Licensure Compact Law
• Minimum of 3 years of clinical nursing experience
• Experience in appeals and grievance processes, with knowledge of Medicare, CMS, and TennCare regulations
• Strong analytical skills and attention to detail
• Familiarity with AI tools for improving efficiency is a plus