Appeals Analyst RN

Hornet Staffing, Inc, a GEE Group company; Columbia (SC); In loco; USD 65.000 - 85.000; Tempo pieno

Descrizione del lavoro

Hornet Staffing, Inc., a GEE Group company, seeks an RN reviewer to join our clinical review team in the United States. The role focuses on reviewing medical records, determining medical necessity, and evaluating provider appeals/denials with attention to coding accuracy and policy adherence.

The incumbent will rely on 3 years of clinical experience (or 2 years plus 1 year in utilization/medical review, quality assurance, or home health) and hold an active RN license.

Competenze

• 3 years of clinical experience, or 2 years of clinical experience plus 1 year in utilization/medical review, quality assurance, or home health.
• Active RN license in the state of hire or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• Healthcare insurance experience preferred.

Mansioni

• Researches and reviews medical records and provider appeals/denials to determine medical necessity and appropriate coverage.
• Documents decisions and ensures they meet mandated timeframes and regulatory standards.

Conoscenze

Active RN license

Formazione

Associate Degree in Nursing or graduate of an accredited School of Nursing

Descrizione del lavoro

- 3 years of clinical experience; or 2 years of clinical experience plus 1 year of utilization/medical review, quality assurance, or home health experience

- Associate Degree in Nursing or graduate of an accredited School of Nursing

- Active, unrestricted RN license in the state of hire or active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)

- Healthcare insurance experience preferred

Day-to-day work will focus heavily on reviewing medical records and provider appeals/denials, confirming appropriate coding, and determining whether a denial should be upheld or overturned.

Manager is specifically looking for candidates who demonstrate dependability and accountability.

Duties:

• Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment, medical and pharmacy review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested. services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
• Job Description: Documents the basis of the appeal or retrospective review in an accurate and timely manner and accordance with 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, authorizations 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 applying 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.