RN Appeals Analyst (Must Reside in SC)

About the Role

As an RN Appeals Analyst, you will research the substance of complex appeal or retrospective review requests, including pre-pay and post-payment review appeal requests. You will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines and document decisions within mandated timeframes and in compliance with applicable regulations or standards.

Schedule

This is a full-time (40 hours/week) position with working hours from 8:00 AM to 4:30 PM EST, Monday through Friday. The role is fully remote, though the candidate will be required to report on-site the first week to retrieve equipment and occasionally throughout the year for trainings, meetings, or other business needs.

Responsibilities

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and/or application to benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Requirements

• Required Education: Associate's degree in a job-related field or graduate of an accredited School of Nursing.
• Required Work Experience:
  • 2 years of clinical experience plus 1 year of 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 of utilization/medical review, quality assurance, or home health experience, or a combination of experience in clinical, utilization/medical review, quality assurance, or home health totaling four years.
• Required Skills and Abilities:
  • Working knowledge of word processing software.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Working knowledge of managed care and various forms of health care delivery systems.
  • Strong clinical experience to include home health, rehabilitation, and/or broad medical-surgical experience.
  • Knowledge of specific criteria/protocol sets and the use of the same.
  • Good judgment skills.
  • Demonstrated customer service, organizational, oral, and written communication skills.
  • Ability to persuade, negotiate, or influence others.
  • Analytical or critical thinking skills.
  • Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.
• Required License and Certificate: 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).

Preferred Qualifications

• Preferred Education: Bachelor's degree in Nursing.
• Preferred Work Experience: 3 years of utilization/medical review, quality assurance, or home health, plus 5 years of clinical experience.
• Preferred Skills and Abilities:
  • Knowledge of Administrative Law Judge (ALJ) process.
  • Knowledge of statistical principles.
  • Knowledge of National Committee for Quality Assurance (NCQA).
  • Knowledge of Utilization Review Accreditation Commission (URAC).
  • Knowledge of South Carolina Department of Insurance (SCDOI).
  • Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations.
  • Excellent organizational and time management skills.
  • Knowledge of claims systems.
  • Presentation skills.
• Preferred Software and Other Tools: Excel or other spreadsheet software; ability to effectively use Microsoft Office applications such as Word, PowerPoint, and Excel.

Benefits

We offer our employees a comprehensive benefits package, with eligibility beginning the first of the month following 28 days of employment.

• Subsidized health plans, dental, and vision coverage.
• 401k retirement savings plan with company match.
• Life Insurance.
• Paid Time Off (PTO).
• On-site cafeterias and fitness centers in major locations.
• Education Assistance.
• Service Recognition.
• National discounts to movies, theaters, zoos, theme parks, and more.