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RN - Appeals Analyst

Health Care | Columbia, SC | Temp to Perm

Job Description

RN / Appeals Analyst

InGenesis Solutions has an opportunity for an RN/Appeals Analyst to come and join our client located in Columbia, SC! As the RN/Appeals Analyst with a large health insurance provider, 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 time frames and in compliance with applicable regulations or standards.

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:

  • Active RN license in South Carolina

  • 3+ years of clinical experience

  • Solid computer skills

  • Excellent attention to detail

  • Ability to work independently

INGENESIS OFFERS:

  • Competitive Salary

  • Paid Time Off

  • Paid Federal Holidays

  • Medical, Dental, Vision Health Insurance Plans

  • 401K Retirement Plan

  • Life and Disability Insurance


ABOUT US

Established in 1998, InGenesis enjoys a long history of positive government and commercial relationships with healthcare industry professionals and businesses nationwide. We are the recent recipients of an Inc. 5000 award and dedicated to servicing our customers.

InGenesis is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.

RN / Quality Improvement Coordinator 

InGenesis Solutions has a unique opportunity available for an RN/Quality Improvement Nurse to join our client’s team located in Columbia, SC.    As the Quality Improvement Nurse, you will be accountable for ensuring that all patients receive a consistent level of quality care. Specifically, you’ll oversee analyzing various process and procedures used in patient care and ensuring all patients receive correct care based on these standards. It is critical that you stay on top of current nursing practices and possess the ability to pay strong attention to details.

Overall Purpose of the Position:

  • Monitors/implements quality improvement/management activities.

  • Conducts specific medical reviews as necessary, analyzes findings, makes recommendations for corrective actions, and prepares formal documentation for compliance with applicable standards/regulations.  

  • Performs Health Plan Employer Data Information Set data collection (HEDIS), and National Committee for Quality Assurance (NCQA) accreditation activities.


Responsibilities of Job:

  • Performs quality improvement activities to monitor/maintain compliance with applicable standards/regulations.

  • Analyzes/documents/presents findings of quality improvement activities.  Recommends corrective action and improvement when

  • necessary.

  • Conducts quality medical record reviews to monitor quality of care and service provided.   Tracks/trends/investigates quality concerns and complaints.

  • Coordinates HEDIS data collection.


Qualifications:

  • Active RN license in South Carolina

  • 4+ years clinical experience

  • Excellent communication skills


INGENESIS OFFERS:

  • Competitive Salary

  • Paid Time Off

  • Paid Federal Holidays

  • Medical, Dental, Vision Health Insurance Plans

  • 401K Retirement Plan

  • Life and Disability Insurance


ABOUT US

Established in 1998, InGenesis enjoys a long history of positive government and commercial relationships with healthcare industry professionals and businesses nationwide. We are the recent recipients of an Inc. 5000 award and dedicated to servicing our customers.

InGenesis is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, or national origin.

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