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-pay and post-payment evaluations

• Execute clinical assessments or benefit evaluations to ascertain medical necessity

• Accurately and promptly document appeal and retrospective review outcomes, ensuring compliance with regulations and standards

• Analyze member and provider service appeals utilizing clinical documentation, contractual obligations, agency guidelines, policies, and procedures

• Implement policies, procedures, benefit provisions, and clinical information to identify relevant issues and precedents

• Safeguard confidential health information

• Undertake special projects, including the review of clinical information to identify quality-of-care concerns

⛳️ Requirements

• Associate's degree in a related field

• Graduate of an Accredited School of Nursing as equivalent to degree

• Four years of relevant experience: 2 years of clinical experience along with 2 years in utilization/medical review, quality assurance, or home health, or an equivalent combination totaling four years

• Active and unrestricted RN license from the United States and in the state of hire, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact

• Proficient in word processing software

• Familiarity with managed care and various healthcare delivery systems

• Strong clinical background, including home health, rehabilitation, and/or extensive medical-surgical experience

• Understanding of specific criteria/protocol sets and their application

• Proficient in Microsoft Office

• Capability to work independently, prioritize tasks effectively, and make informed decisions

• Excellent judgment, customer service, organizational, oral and written communication, persuasion, negotiation, influence, analytical, and critical-thinking skills

• Ability to manage confidential or sensitive information with care

• Preferred: 5 years of clinical experience

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

• Preferred: experience with Medicare Part B

• Preferred: strong computer skills, familiarity with dual-screen workflows, intermediate Excel abilities, and experience in creating accurate letters and documents for appeals

🏝️ Benefits

• Subsidized health plans, dental and vision coverage

• 401k retirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• Education Assistance

• Service Recognition

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