Clinical Appeals Analyst Jobs

• Review and interpret product and benefit designs according to State and Federal regulatory requirements

Education: Associates Degree or equivalent experience in health care, conflict resolution or related field.

• Health care benefit and regulatory knowledge preferred

• 3-5 years health care or insurance experience

• Knowledge of insurance products, policies and procedures preferred.

• Requires excellent interpersonal skills in order to communicate and work with multiple constituents.

5 years of analytical skills and experience (query data, excel, and SharePoint)

Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.

Guides staff by providing technical knowledge and functions as a subject matter expert to staff.

Experience with process improvement initiatives

Serves as a lead for incoming analysts by providing support.

Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.

Excellent organizational and time management skills.

Continuing education funds for additional certifications and certification renewal

Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical.

Working knowledge of word processing software.

Strong clinical experience, including home health, rehabilitation, and broad medical surgical experience.

Knowledge of specific criteria/protocol sets and the use of the same.

Experience working in care management systems, such as CCMS, TruCare or Hyland

Prior experience in a Managed Care or Healthcare environment

Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes and exceptional organizational skills.

Manage all duties within regulatory timeframes

Bachelor’s degree from an accredited institution or relevant work experience

Prior knowledge of Medicare and Medicaid health plans

Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements

Health care benefit and regulatory knowledge preferred

Must be able to work under normal office conditions and in a remote capacity from home as required.

Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.

Associates Degree or equivalent experience in health care, conflict resolution or related field

3-5 years health care or insurance experience

Pharmacy reimbursement (third party insurance, Medicare Part D formulary management, Medicaid, and Commercial

Position requires excellent record keeping skills, thorough documentation, clear and concise written/verbal communications skills

2+ years of working experience as a licensed Pharmacist

Experience using online clinical references and accessing professional (clinical and regulatory) internet sites

Experience working with onscreen document images

Proven excellent written and verbal communication skills

Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.

12898 Towne Center Drive, Cerritos, CA

3080 Bristol Street, Costa Mesa, CA

11030 White Rock Road, Rancho Cordova, CA

1121 L St., Suite 500, Sacramento, CA

2121 N. California Boulevard, Walnut Creek, CA

At least 3 years of case management, concurrent review or utilization management experience

Prepare professional, effective clinical appeals in response to managed care, governmental, or RAC denials for hospital clients.

At least 5 years of clinical experience in acute care setting

Participate in telephonic Administrative Law Judge Hearings and present oral arguments for reversing Medicare denials.

Bachelor of Science degree in Nursing

Proficiency in medical record review

At least 1 year of case management experience required

Relevant education may substitute experience requirement

Education assistance (tuition, student loan, certification support, dependent scholarships)

Family support through fertility and family building benefits with Progyny and adoption assistance.

Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Demonstrate the ability to interpret medical payer policy requirements.

Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity.

Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes.

Three (3) years of acute care experience or equivalent expertise.

Two (2) years’ experience in utilization review.

Strong attention to detail with excellent communication skills in both written and verbal forms.

2+ years experience working in the Epic system.

Review clinical information and consider Utilization Management Criteria and Corporate Medical Policy to determine medical necessity and appropriateness of care

3 + years of health insurance experience, preferably in claims or customer service

Salary: $35-$38/hr. based on relative experience

Comprehensive Benefits: Medical, Dental, Vision, 401k

Responsibilities of the RN Clinical Appeals Analyst:

Qualifications of the RN Clinical Appeals Analyst: