RN Appeals Analyst

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

📋 Description

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

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

• Accurately document appeal and retrospective review outcomes within required timeframes, ensuring compliance with relevant regulations or standards.

• Explore member and provider service appeals by utilizing clinical documentation, contractual obligations, governing agency guidelines, policies, and procedures.

• Uphold confidentiality while managing protected health information.

• Identify and establish precedence for relevant issues when implementing policies, procedures, clinical data, benefit provisions, or policy stipulations.

• Undertake special projects, which may include reviewing clinical data to pinpoint quality-of-care concerns.

⛳️ Requirements

• Associate degree in Nursing or a graduate from an accredited School of Nursing.

• Minimum of two years of clinical experience plus one year in utilization/medical review, quality assurance, or home health; alternatively, three years of clinical experience.

• Proficient in word processing software.

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

• Familiarity with managed care and diverse health care delivery systems.

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

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

• Possess sound judgment skills.

• Proven customer service, organizational, and effective oral and written communication abilities.

• Skilled in persuading, negotiating, or influencing others.

• Strong analytical or critical thinking capabilities.

• Capacity to manage confidential or sensitive information discreetly.

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

• Compliance with CMS residency requirements for specific divisions: must have resided in the U.S. for at least three out of the last five years.

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

• Preferred: Bachelor's degree in Nursing.

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

🏝️ Benefits

• 401(k) retirement savings plan with company matching contributions.

• Subsidized health plans along with complimentary vision coverage.

• Life insurance coverage.

• Paid annual leave that increases with tenure.

• Nine paid holidays each year.

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

• Wellness programs and discounts for maintaining a healthy lifestyle.

• Tuition assistance for continued education.

• Recognition for service longevity.

• Incentive Plan to reward performance.

• Merit-based compensation plan.

• Funding for continuing education to support additional certifications and renewal of existing certifications.