RN Appeals Analyst – SC, GA

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

📋 Description

• Conduct thorough research on intricate appeal and retrospective review requests, encompassing both pre-pay and post-payment review appeals.

• Execute clinical reviews or benefit analyses to ascertain if the requested services align with medical necessity guidelines.

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

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

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

• Comply with confidentiality regulations concerning protected health information.

• Conduct appeal and retrospective reviews by applying relevant policies, procedures, clinical information, and benefit or policy stipulations.

• Undertake special projects, which include reviewing clinical information to identify quality-of-care concerns.

⛳️ Requirements

• Associate's degree in a relevant field.

• Graduate from an accredited nursing school.

• A minimum of 2 years of clinical experience along with 1 year in utilization/medical review, quality assurance, or home health, OR 3 years of clinical experience.

• For Palmetto GBA (Co. 033) specifically: 2 years of clinical experience plus 2 years in utilization/medical review, quality assurance, or home health experience, or a combination of experience totaling four years.

• Proficient in word processing software.

• Familiarity with managed care and various healthcare delivery systems.

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

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

• Proficiency in Microsoft Office.

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

• Capability to work independently, prioritize tasks effectively, and make informed decisions.

• Strong judgment, analytical or critical thinking skills, along with excellent customer service, organizational, and oral and written communication abilities.

• Ability to persuade, negotiate, or influence others.

• Capacity to manage confidential or sensitive information with discretion.

🏝️ Benefits

• Subsidized health insurance plans, including dental and vision coverage.

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

• Life insurance coverage.

• Paid Time Off (PTO).

• Access to on-site cafeterias and fitness centers at major locations.

• Education assistance programs.

• Service recognition awards.

• National discounts for movies, theaters, zoos, theme parks, and more.