RN Appeals Analyst, SC

job requisition id R1048039

Summary

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 full-time position (40 hours/week), Monday through Friday, with flexible hours between 7:30 AM and 5:00 PM. The role is fully remote following completion of onsite training at our Columbia, SC office (4101 Percival Road, Columbia, SC 29229). Candidates must be located reputed company two hours of a reputed company office to accommodate occasional in-office visits as needed. What You Will Do:

• 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.

To Qualify for This Position, You Will Need the Following:

• Required Education: Associate's in a job reputed company field.
• Degree Equivalency: Graduate of Accredited School of Nursing.
• Required Experience: 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.
• Required Skills and Abilities: 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.
• Required License and Certificate: 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).
• Required Software and tools: reputed company Office.
• Work Environment: Typical office environment. Deadline driven environment.

We Prefer That You Have the Following:

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

Our comprehensive benefits package includes the following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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

reputed company Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across reputed company spectrums have the opportunity to reputed company their skills, advance their careers and contribute their unique abilities to the growth of our company. Equal Employment Opportunity Statement reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national reputed company, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in reputed company phases of the employment process and to reputed company with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-reputed company conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email reputed [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will reputed company a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Apply tot his job Apply To this Job