Appeals Registered Nurse # 26-28152

US Tech Solutions; Columbia (SC); On-site; USD 55,000 - 83,000; Full time

Job summary

Us Tech Solutions is seeking an RN reviewer to support medical record reviews and provider appeals/denials under a 3-month contract. The role focuses on confirming coding accuracy and deciding whether denials should be upheld or overturned, with emphasis on dependability and accountability.

The candidate should hold an Associate Degree in Nursing, active SC RN licensure, and have 3 years of clinical experience (or 2 years plus 1 year in utilization/medical review, QA, and home health).

Qualifications

• Proficient in standard word processing tools.
• Knowledge of quality improvement processes and ability to apply them.
• Familiarity with contract language and its application.
• Ability to work independently, prioritize, and make sound decisions.
• Good judgment and problem-solving skills.
• Strong customer service, organizational, and presentation skills.
• Excellent oral and written communication abilities.
• Ability to persuade, negotiate, or influence others.
• Ability to handle confidential information discreetly.

Responsibilities

• Research complex appeal or retrospective review requests including pre-pay and post-payment cases.
• Provide clinical review or benefit analysis to determine medical necessity.
• Document decisions within mandated timeframes and regulations.
• Explain the basis of appeals in documentation consistent with standards.
• Thoroughly research service appeals based on clinical documentation and contractual requirements.
• Adhere to confidentiality regulations governing protected health information.
• Perform appeal and retrospective reviews to define precedence of issues when applying policies.
• Lead special projects including reviews of clinical information to identify quality-of-care issues.

Skills

Word processing

Quality improvement

Contract language

Independent work

Decision making

Customer service

Communication skills

Analytical thinking

Confidential information handling

Education

Associate Degree - Nursing

Job description

Duration: 3 MonthsContract

• Hour/Schedule: Monday-Friday, typically 8am-5pm.
• Training - \"One on One\" | On-the-job.
• Typical day: 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.
• Looking for candidates who demonstrate dependability and accountability.

Job Description

• Hour/Schedule: Monday-Friday, typically 8am-5pm.
• Training - \"One on One\" | On-the-job.
• Typical day: 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.
• Looking for candidates who demonstrate dependability and accountability.

Responsibilities

• 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.
• 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.

Experience

• 3 years of clinical or 2 years of clinical experience plus 1 year utilization/medical review, quality assurance, and home health experience.

Skillsets

• Working knowledge of word processing software.
• Knowledge of quality improvement processes and demonstrated ability with these activities.
• Knowledge of contract language and application.
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills.
• Demonstrated customer service, organizational, and presentation skills.
• Demonstrated 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.

Education

• Associate Degree - Nursing.

Additional Qualifications

• Licenses: Active SC unrestricted RN licensure
• Shift Hours: Monday through Friday, 8:00AM-5:00PM

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.

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