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RN / Appeals Analyst (KS-APM-PV)

Nursing | Columbia, SC | Full Time

Job Description

RN / Appeals Analyst

We have 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 a 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.

Responsibilities of Job:

  • 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 the ability to define and determine the 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 the quality of care issues.

Requirements:

  • Active & unrestricted RN license in South Carolina
  • Minimum of 3 years clinical experience
  • Solid computer skills
  • Excellent attention to detail
  • Ability to work independently

We support a diverse workforce and is an Equal Opportunity Employer who does not discriminate against employees and applicants for employment on the basis of race, gender, color, religion, national origin, age, sexual orientation, gender identity, genetic information, disability, veteran status, or other classification protected by law.