Mindlance · 12 hours ago
Clinical Appeals Analyst
United States
Full-time
Remote
Mid, Senior Level
3+ years expMindlance is a company seeking a Clinical Appeals Analyst to provide clinical consultation within their Appeals Department. The role involves coordinating the appeals process, analyzing complex member and provider appeals, and ensuring compliance with various medical and legislative requirements.
Human Resources
Responsibilities
Provide clinical consultation with 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, NCDOI, legislative, federal and NCQA requirements, as applicable
Assist with Level 3 appeals as required
Analyze complex/non-routine member and provider appeals and grievances for all lines of business, excluding FEP, by reviewing CMP, contract provisions, legislation and/or NCQA requirements
Identify appropriate documentation collection from multiple external sources such as pharmaceutical companies, attorneys, providers, etc
Present analysis and documentation to appropriate physician committee, benefit administrators and BCBSNC leadership, as necessary
Initiate claim adjustments on individual cases when necessary
Provide written documentation of case determinations to appellants and/or all involved parties in a timely manner as required by mandates and legislation
Identify trends and high-risk issues to make recommendations to address future exposure
Identify and take corrective action on appeals that result from noncompliance of contract provisions, appeal guidelines and/or CMP
Create action plans to educate internal employees of benefit misinterpretation and/or claim system errors
Answer member/provider questions via incoming telephone calls in a professional quality driven manner
May handle complaints/grievances as defined by the federal government
Coordinates with external vendors and provides requested information as requested
Qualification
Required
Registered Nurse in the state of North Carolina
3 years of clinical experience
OR Licensed Practical Nurse, Physical Therapist, Occupational Therapist
Licensed in the State of North Carolina and 5 years of clinical experience
Company
Mindlance
Mindlance is a Staffing and Recruiting company which provides multi-vertical staffing services
1001-5000 employees
H1B Sponsorship
Mindlance has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (71)
2024 (53)
2023 (37)
2022 (72)
2021 (36)
2020 (40)
Funding
Current Stage
Late StageLeadership Team
R
Rajat Paul Dhall
Co-Founder & Managing Director
V
Vik Kalra
Co-Founder and Managing Director
Recent News
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