Analyst, Appeals

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

📋 Description

• Conducts in-depth research on complex appeal or retrospective review requests, including both pre-pay and post-payment appeal inquiries.

• Delivers comprehensive clinical evaluations or benefit analyses to assess if the requested services align with medical necessity standards.

• Records decisions within required timelines and in accordance with relevant regulations or standards.

• Engages in extensive research of service appeal content from both members and providers, utilizing clinical documentation, contractual obligations, regulatory agency requirements, policies, and procedures, while maintaining confidentiality regarding protected health information.

• Executes appeal and retrospective reviews showcasing the ability to identify and prioritize key issues in the application of policies and procedures to clinical data and/or application to benefit or policy provisions.

• Undertakes special projects, including clinical information reviews aimed at identifying quality of care concerns.

⛳️ Requirements

• Required Education: Associate's degree in a related field.

• Degree Equivalency: Graduate of an Accredited School of Nursing.

• Required Work Experience: 2 years of clinical experience plus 1 year in utilization/medical review, quality assurance, or home health, OR, 3 years of clinical experience.

• Required Skills and Abilities: Proficient knowledge of word processing software.

• Ability to work autonomously, effectively prioritize tasks, and make informed decisions.

• Familiarity with managed care and various healthcare delivery systems.

• Strong clinical background, including experience in home health, rehabilitation, and/or broad medical-surgical settings.

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

• Excellent judgment capabilities.

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

• Ability to persuade, negotiate, or influence others effectively.

• Analytical or critical thinking abilities.

• Capability to manage confidential or sensitive information with care.

• Required Software and Tools: Proficiency in Microsoft Office.

• Required License and Certificate: An active, unrestricted RN license from the United States and in the state of hire, OR, an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

🏝️ Benefits

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

• 401k retirement savings plan featuring company matching.

• Life insurance coverage.

• Paid Time Off (PTO).

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

• Education assistance programs.

• Service recognition initiatives.

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