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 review appeals.

• Conduct clinical evaluations or benefit analyses to ascertain if the requested services align with medical necessity guidelines.

• Accurately document the basis for appeals or retrospective reviews in a timely manner, adhering to regulations and standards.

• Examine service appeals from members and providers utilizing clinical documentation, contractual obligations, governing agency standards, policies, and procedures.

• Implement confidentiality regulations concerning protected health information.

• Identify and prioritize relevant issues when applying policies, procedures, clinical data, and benefit or policy stipulations.

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

• Complete training that lasts approximately 8 to 12 weeks.

• Work Monday through Friday, 40 hours a week, in an 8-hour shift during business hours; post-training, shifts may commence as early as 6:00 a.m. Eastern Time.

⛳️ Requirements

• An Associate's degree in a relevant field.

• Graduation from an Accredited School of Nursing as an equivalent degree.

• A total of four years of combined experience in clinical, utilization/medical review, quality assurance, or home health settings, which includes 2 years of clinical experience along with 2 years in utilization/medical review, quality assurance, or home health.

• Proficient in word processing software.

• Familiarity with managed care and various healthcare delivery systems.

• Substantial clinical experience, including home health, rehabilitation, and/or extensive medical-surgical experience.

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

• Excellent judgment skills.

• Proven customer service, organizational, and oral and written communication skills.

• Capability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking abilities.

• Competence in managing confidential or sensitive information with discretion.

• Proficiency in Microsoft Office.

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

• Preferably experienced in medical claims processing, appeals, or coding.

• Medicare Part B experience is preferred.

• High computer proficiency, including navigating multiple systems and operating dual screens.

• Intermediate-level skills in Excel.

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

🏝️ Benefits

• Subsidized health plans, along with dental and vision coverage.

• 401k retirement savings plan with company matching.

• Life insurance coverage.

• Paid Time Off (PTO).

• On-site cafeterias and fitness centers at major locations.

• Education assistance programs.

• Service recognition initiatives.

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