Analyst, Appeals

This is a fully remote position, open to applicants in South Carolina.

📋 Description

• Investigate intricate appeal and retrospective review requests, encompassing both pre-payment and post-payment appeals.

• Perform clinical assessments or benefit evaluations to ascertain if the requested services fulfill medical necessity standards.

• Accurately document decisions regarding appeals and retrospective reviews in a timely manner, adhering to relevant regulations or standards.

• Analyze member and provider service appeals utilizing clinical documentation, contractual obligations, regulatory agencies, policies, and procedures.

• Implement policies, procedures, clinical data, benefit provisions, and precedents during appeal and retrospective reviews.

• Undertake special projects, which include examining clinical information to pinpoint quality-of-care concerns.

• Complete roughly 8–12 weeks of training prior to commencing the regular shift.

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate of an Accredited School of Nursing recognized as degree equivalency.

• Two years of clinical experience along with two years of utilization/medical review, quality assurance, or home health experience, or a total of four years' experience in a combined capacity.

• Proficient in word processing software.

• Familiarity with managed care and various healthcare delivery systems.

• Extensive clinical experience, including home health, rehabilitation, and/or diverse medical-surgical exposure.

• Understanding of specific criteria/protocol sets and their applications.

• Proficient in Microsoft Office.

• Possession of an active, unrestricted RN license from the United States and the state of hire, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC).

• Experience in medical claims processing, appeals, or coding is highly preferred.

• Medicare Part B experience is preferred.

• Strong computer skills, including the ability to navigate multiple systems and work efficiently across dual screens.

• Intermediate-level skills in Excel.

• Experience in drafting letters and documents by reviewing appeals and accurately extracting information.

• Ability to work autonomously, prioritize tasks effectively, make informed decisions, persuade, negotiate, or influence others, and manage confidential or sensitive information with discretion.

• Proven judgment, customer service, organizational, oral and written communication, analytical, and critical thinking abilities.

🏝️ Benefits

• Subsidized health plans, dental and vision coverage.

• 401k retirement savings plan with company matching.

• Life Insurance.

• Paid Time Off (PTO).

• On-site cafeterias and fitness centers available in major locations.

• Education Assistance.

• Service Recognition.

• National discounts for movies, theaters, zoos, theme parks, and more.