Review and process appeals submitted by members and providers, ensuring timely and accurate resolution in compliance with CMS, Medicare, and TennCare guidelines.
Evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times.
Review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24–72 hours.
Ensure timeliness and quality is met per regulations/guidelines.
Utilize multiple systems in order to appropriately research and document the substance and validity of the appeal or QOC grievance.
Evaluate and research medical necessity documentation submitted for clinical review including complex situations.
Conduct outreach as applicable for clinical information and preparing case files for the Medical Director to review.
Create detailed member and provider specific individualized appeal and QOC grievance response letters; assess appeal and QOC grievance response letters for accuracy and compliance as well as providing recommendations for improvement, if needed.
Work collaboratively with the clinical and non-clinical staff for appropriate resolution of appeals and quality of care cases.

3 years
Clinical nursing experience required
Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Must be a team player, be organized and have the ability to handle multiple projects
Excellent oral and written communication skills
Strong interpersonal and organizational skills
Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Appeals & Grievance Nurse Analyst

Key skills