Appeals Analyst

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

📋 Description

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

• Execute comprehensive clinical assessments or benefit evaluations to ascertain if the requested services comply with medical necessity criteria.

• Record decisions within required timeframes while adhering to relevant regulations or standards.

• Accurately and promptly document the foundations of appeals or retrospective reviews.

• Analyze member and provider service appeals utilizing clinical documentation, contractual stipulations, governing body guidelines, policies, and procedures.

• Comply with confidentiality regulations pertaining to protected health information.

• Conduct appeal and retrospective reviews, establishing the precedence of relevant issues when applying policies, procedures, clinical data, benefits, or policy stipulations.

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

• Operate in a deadline-oriented remote work environment.

⛳️ Requirements

• Associate's degree in a related field, or completion of an accredited nursing program.

• Active, 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).

• Proficient in word processing software.

• Capability to work independently, prioritize tasks efficiently, and make well-informed decisions.

• Familiarity with managed care and various healthcare delivery systems.

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

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

• Excellent judgment skills.

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

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

• Strong analytical or critical thinking capabilities.

• Proficient in handling confidential or sensitive information with care.

• Proficiency in Microsoft Office.

• Availability for full-time hours, 40 hours per week, Monday through Friday, from 8:00 am to 5:00 pm.

• This position does not qualify for sponsorship now or in the future.

🏝️ Benefits

• Subsidized health insurance 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 available in major locations.

• Education assistance programs.

• Service recognition initiatives.

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

• Commitment to a diverse and inclusive workplace.

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

• Benefits eligibility commences on the first of the month following 28 days of employment.