RN Appeals Analyst

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

📋 Description

• Conducts in-depth research on complex appeal or retrospective review requests, including pre-pay and post-payment review appeals.

• Performs detailed clinical evaluations or benefit analyses to assess whether the requested services satisfy medical necessity standards.

• Records decisions within required timeframes while adhering to relevant regulations and standards.

• Engages in comprehensive research regarding the substance of service appeals from both members and providers, utilizing clinical documentation, contractual obligations, governing agency requirements, policies, and procedures, all while maintaining confidentiality of protected health information.

• Executes appeal and retrospective reviews, showcasing the ability to identify and prioritize crucial issues in the application of policies and procedures to clinical information and/or the interpretation of benefit or policy provisions.

• Undertakes special projects that involve reviewing clinical information to pinpoint quality of care concerns.

⛳️ Requirements

• Associate degree in a relevant field.

• Graduate from an Accredited School of Nursing.

• Two years of clinical experience plus one year in utilization/medical review, quality assurance, or home health, OR three years of clinical experience. FOR PALMETTO GBA (CO. 033) ONLY: Two years of clinical experience plus two years in utilization/medical review, quality assurance, or home health experience, or a combination of experiences in clinical, utilization/medical review, quality assurance, or home health totaling four years.

• Proficient in word processing software.

• Ability to work autonomously, prioritize tasks effectively, and make informed decisions.

• Familiarity with managed care and various healthcare delivery systems.

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

• Knowledge of specific criteria/protocol sets and their applications.

• Excellent judgment skills.

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

• Capable of persuading, negotiating, or influencing others.

• Strong analytical or critical thinking skills.

• Ability to manage confidential or sensitive information with care.

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

🏝️ 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 for movies, theaters, zoos, theme parks, and more.