Healthcare Appeals Analyst

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

• Complete training on Medicare, insurance processes, and appeals workflows
• Shadow experienced team members and transition to independent case review
• Begin managing a caseload, focusing on clinical review and compliance

Compensation

Salary Range: $70,000 - $80,000 with company subsidized medical, dental, and vision benefits