RN Appeals Analyst

This is a fully remote position, open to applicants in Alabama, +45 more states.

📋 Description

• Conduct research on the details of intricate appeal or retrospective review requests, including both pre-pay and post-payment review appeals.

• Deliver comprehensive clinical assessments or benefit analyses to ascertain if requested services comply with medical necessity standards.

• Record decisions within mandated timelines and in accordance with relevant regulations or standards.

• Accurately and promptly document the rationale behind appeals or retrospective reviews.

• Investigate member and provider service appeals utilizing clinical documentation, contractual obligations, governing agency requirements, policies, and procedures.

• Comply with confidentiality regulations concerning protected health information.

• Execute appeal and retrospective reviews while identifying the precedence of relevant issues in the application of policies, procedures, clinical data, benefits, or policy provisions.

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

⛳️ Requirements

• Associate Degree in Nursing or a Graduate of an Accredited Nursing School.

• Two years of clinical experience plus one year in utilization/medical review, quality assurance, or home health, OR three years of clinical experience.

• Proficient in word processing software.

• Capable of working independently, effectively prioritizing tasks, and making sound decisions.

• Familiarity with managed care and various healthcare delivery systems.

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

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

• Strong judgment skills.

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

• Ability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking abilities.

• Ability to manage confidential or sensitive information with discretion.

• 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).

• Compliance with CMS residency requirements for certain divisions: must have lived in the US for at least three of the last five years.

• Preferred: Three years of experience in utilization/medical review, quality assurance, or home health, in addition to five years of clinical experience.

• Preferred: Bachelor's degree in Nursing.

• Preferred familiarity with the Administrative Law Judge (ALJ) process, statistical principles, NCQA, URAC, SCDOI, US DOL, HIPAA standards/regulations, claims systems, and presentation skills.

• Exceptional organizational and time management skills.

🏝️ Benefits

• 401(k) retirement savings plan with company match.

• Subsidized health plans and complimentary vision coverage.

• Life insurance coverage.

• Paid annual leave – the longer you stay, the more you accumulate.

• Nine paid holidays each year.

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

• Wellness programs and discounts for maintaining a healthy lifestyle.

• Tuition assistance for further education.

• Recognition for years of service.

• Incentive Plan to reward performance.

• Merit Plan for outstanding contributions.

• Continuing education funds available for additional certifications and for certification renewal.