Clinical Appeals Analyst

ManpowerGroup • Durham, NC • 15h ago

Join a mission-driven healthcare organization where your clinical expertise directly influences fair, accurate, and timely appeal determinations for members and providers. This role is ideal for an experienced clinician who thrives in a detail-driven environment and enjoys collaborating with both clinical and non-clinical teams to ensure compliance, quality, and exceptional service.

Location: Durham, NC

Pay Rate: $39 - 46 per hour

Employment Type: Temporary / Contract

Start Date: ASAP

Assignment Length: Through approximately 12/31/2026

Why This Role Matters

In this role, you will serve as the clinical expert within the Appeals Department, ensuring appeal cases are managed accurately, consistently, and in full compliance with state, federal, and organizational requirements. Your clinical judgement and attention to detail will help safeguard members' rights, support regulatory compliance, and address trends that improve long-term outcomes.

What You'll Do

Provide clinical consultation to non-clinical staff within the Appeals Department.

Coordinate all aspects of the appeals process, ensuring compliance with medical necessity criteria, Corporate Medical Policy (CMP), contract provisions, NCDOI requirements, federal regulations, and NCQA standards.

Assist with Level 3 appeals when required.

Review and analyze complex or non-routine member and provider appeals across all lines of business (excluding FEP).

Identify and collect essential documentation from external sources (pharmaceutical companies, attorneys, providers, etc.).

Present findings and case analyses to physician committees, benefit administrators, and organizational leadership.

Initiate claim adjustments on individual cases when needed.

Generate written determinations in compliance with mandated timelines.

Identify high-risk issues and trends; recommend strategies to prevent future exposure.

Address and correct appeal cases arising from contract noncompliance, guideline issues, and/or CMP misinterpretations.

Develop and deliver action plans to educate employees on benefit interpretation and claim system issues.

Respond to professional inquiries via phone in a quality-driven manner.

Handle grievances/complaints as defined by federal guidelines.

Coordinate with external vendors and provide requested case information.

What We're Looking For

A current, up-to-date resume

Registered Nurse licensed in North Carolina with 3+ years of clinical experience , OR

Licensed Practical Nurse, Physical Therapist, or Occupational Therapist licensed in North Carolina with 5+ years of clinical experience

Strong knowledge of medical necessity criteria, clinical documentation, and regulatory requirements

Excellent analytical skills and the ability to interpret complex clinical and contractual guidelines

Strong written and verbal communication skills

Ability to work independently and collaborate cross-functionally

Ability to meet compliance requirements

What's In It For You

Opportunity to apply clinical expertise in a non-traditional setting

Stable assignment running through the end of 2026

Professional collaboration with clinical and operations leaders

Meaningful work that impacts member experience and organizational quality outcomes

Benefits for Manpower Associates (Upon Eligibility)

Medical, dental, disability, and life insurance

401(k) retirement plan

Full tuition coverage

Employee Assistance Program

Referral bonuses

And more!

ManpowerGroup is committed to providing equal employment opportunities in a professional, high quality work environment. It is the policy of ManpowerGroup and all of its subsidiaries to recruit, train, promote, transfer, pay and take all employment actions without regard to an employee's race, color, national origin, ancestry, sex, sexual orientation, gender identity, genetic information, religion, age, disability, protected veteran status, or any other basis protected by applicable law.

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