RN Appeals Analyst – Remote, South Carolina

About the position We are currently hiring for an RN Appeals Analyst to join reputed company. In this role as an RN Appeals Analyst, you will research the substance of reputed company appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Document decisions reputed company mandated timeframes and in compliance with applicable regulations or standards. Why should you join the reputed company family of companies? Other companies come and go, but for more than seven decades we have been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government reputed company. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining reputed company! Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Description Location This is a fully remote position requiring candidates to reside in South Carolina. The role is full-time (40 hours/week), Monday through Friday, with flexible hours between 7:30 AM and 5:00 PM. Following completion of onsite training at a reputed company office, the position transitions to remote work. Candidates must be located reputed company two hours of a company office to accommodate occasional in-office visits.

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

• Associate's in a job reputed company field.
• Graduate of Accredited School of Nursing.
• 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
• FOR reputed company (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years.
• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and reputed company 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.
• An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• reputed company Office.

reputed company-to-haves

• Emergency room ICU experience or broad clinical experience.
• Utilization Management experience.
• Case Management experience.
• Billing or Claims review experience.

Benefits

• 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

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