Analyst, Appeals

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

📋 Description

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

• Conduct comprehensive clinical reviews or benefit analyses to assess whether the requested services align with medical necessity guidelines.

• Accurately and promptly document decisions regarding appeals and retrospective reviews, ensuring compliance with relevant regulations and standards.

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

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

• Safeguard confidential health information throughout the review processes.

• Undertake special projects, which may include evaluating clinical information to identify quality-of-care concerns.

• Complete around 8–12 weeks of training prior to commencing the regular work schedule.

⛳️ Requirements

• An Associate's degree in a relevant field.

• Graduation from an Accredited School of Nursing as a degree equivalency.

• Four years of cumulative experience in clinical, utilization/medical review, quality assurance, or home health, including 2 years of clinical experience and 2 years in utilization/medical review, quality assurance, or home health.

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

• Proficiency in word processing software.

• Familiarity with managed care and various healthcare delivery systems.

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

• Knowledge of specific criteria and protocol sets.

• Strong skills in customer service, organization, and both oral and written communication.

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

• Analytical or critical thinking abilities.

• Aptitude for managing confidential or sensitive information with care.

• Proficiency in Microsoft Office applications.

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

• Intermediate-level Excel capabilities.

• Preferred experience in medical claims processing, appeals, or coding.

• Preferred experience with Medicare Part B.

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

🏝️ 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 at major locations.

• Education Assistance.

• Service Recognition.

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

• A diverse and inclusive workplace.

• Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs.