RN Appeals Analyst, Medicare Part B

📋 Description

• Accurately and promptly documents the foundation of the appeal or retrospective review in compliance with relevant regulations or standards.

• Conducts comprehensive research regarding service appeals from both members and providers, utilizing clinical documentation, contractual obligations, governing regulations, and established policies and procedures, while ensuring confidentiality concerning protected health information.

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

• Engages in special projects, which include reviewing clinical information to pinpoint quality of care concerns.

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate from an Accredited School of Nursing.

• Minimum of 2 years of clinical experience plus 1 year in utilization/medical review, quality assurance, or home health, OR, 3 years of clinical experience.

• FOR PALMETTO GBA (CO. 033) ONLY: 2 years of clinical experience plus 2 years in utilization/medical review, quality assurance, or home health experience, or a cumulative 4 years of experience across clinical, utilization/medical review, quality assurance, or home health.

• Proficient in word processing software.

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

• Familiarity with managed care and various healthcare delivery systems.

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

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

• Excellent judgment skills.

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

• Competence in persuading, negotiating, or influencing others.

• Possesses analytical or critical thinking capabilities.

• Ability to manage confidential or sensitive information with discretion.

• Proficient in Microsoft Office.

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

🏝️ Benefits

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

• Subsidized health insurance plans and complimentary vision coverage.

• Life insurance provided.

• Paid annual leave, with increasing accrual based on 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 educational advancement.

• Recognition for years of service.

• Incentive plans available.

• Merit-based compensation plans.

• Funding for continuing education aimed at additional certifications and renewal of existing certifications.