RN Appeals Analyst

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

📋 Description

• Conduct in-depth research on the details of intricate appeal or retrospective review requests, encompassing both pre-payment and post-payment review appeal requests.

• Execute comprehensive clinical assessments or benefit analyses to ascertain if the requested services adhere to medical necessity guidelines.

• Record decisions within required time frames and in accordance with relevant regulations or standards.

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

• Investigate service appeals submitted by members and providers utilizing clinical documentation, contractual stipulations, regulatory agencies, policies, and procedures.

• Comply with confidentiality regulations pertaining to protected health information.

• Undertake appeal and retrospective reviews by evaluating the significance of relevant issues while applying policies, procedures, clinical data, benefit provisions, or policy provisions.

• Engage in special projects, including the review of clinical information to identify quality-of-care concerns.

⛳️ Requirements

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

• A minimum of two years of clinical experience along with one year in utilization/medical review, quality assurance, or home health, or alternatively, three years of clinical experience.

• Proficient in word processing software.

• Capability 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 settings.

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

• Excellent judgment skills.

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

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

• Strong analytical or critical thinking skills.

• Capacity to manage confidential or sensitive information discreetly.

• 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: employees must have resided 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, paired with five years of clinical experience.

• Preferred: a Bachelor's degree in Nursing.

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

🏝️ Benefits

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

• Subsidized health plans and complimentary vision coverage.

• Life insurance coverage.

• Paid annual leave – the longer you stay with us, 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 healthy lifestyle choices.

• Tuition assistance to support your educational goals.

• Recognition for years of service.

• Incentive Plan to reward performance.

• Merit Plan for salary increases based on performance.

• Continuing education funds for obtaining additional certifications and renewing existing ones.