RN Appeals Analyst, Medicare Part B

📋 Description

• Accurately documents the rationale behind appeals or retrospective reviews in a timely manner, adhering to relevant regulations and standards.

• Conducts comprehensive research into service appeals from both members and providers based on clinical documentation, contractual obligations, governing agencies, policies, and procedures, while maintaining confidentiality regarding protected health information.

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

• Engages in special projects, including the examination of clinical information to pinpoint quality of care concerns.

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate of 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 combined with two years in utilization/medical review, quality assurance, or home health, or a total of four years of experience across clinical, utilization/medical review, quality assurance, or home health.

• Proficient in word processing software.

• Capability to work independently, 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 general medical-surgical settings.

• Understanding of specific criteria/protocols and their application.

• Excellent judgment skills.

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

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

• Strong analytical or critical thinking abilities.

• Capacity to manage confidential or sensitive information with utmost discretion.

• Proficient in Microsoft Office.

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

🏝️ Benefits

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

• Subsidized health plans along with complimentary vision coverage.

• Life insurance provided.

• Paid annual leave – the longer you stay with us, the more you accumulate.

• Nine paid holidays each year.

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

• Wellness programs and discounts for maintaining a healthy lifestyle.

• Tuition assistance available.

• Recognition for service milestones.

• Incentive Plan offered.

• Merit Plan implemented.

• Continuing education funding for additional certifications and renewal of existing certifications.