RN Appeals Analyst

This is a fully remote position, open to applicants in Alabama, +46 more states.

📋 Description

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

• Perform comprehensive clinical reviews or benefit analyses to assess if the requested services align with medical necessity guidelines.

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

• Accurately and timely document the rationale for appeals or retrospective reviews.

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

• Comply with confidentiality regulations concerning protected health information.

• Execute appeal and retrospective reviews by identifying key issues and applying relevant policies, procedures, clinical data, benefit provisions, and policy guidelines.

• Undertake special projects, including the review of clinical information to detect 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, prioritizing tasks effectively, and making informed decisions.

• Familiarity with managed care and various healthcare delivery systems.

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

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

• Excellent judgment skills.

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

• Ability to persuade, negotiate, or influence others.

• Strong analytical or critical thinking skills.

• Capacity 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).

• CMS residency requirement for specific divisions: must have lived in the US for at least three out of the last five years.

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

• Preferred: Bachelor's degree in Nursing.

• Preferred knowledge of the 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 match.

• Subsidized health plans along with complimentary vision coverage.

• Life insurance coverage.

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

• Nine paid holidays throughout the year.

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

• Wellness programs and discounts for maintaining a healthy lifestyle.

• Tuition assistance for further education.

• Recognition for years of service.

• Incentive Plan.

• Merit Plan.

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