Corporate Appeals Analyst

CEI; Columbia (SC); Presencial; USD 56 000 - 76 000; Tempo integral

Resumo da oferta

CEI is seeking a Corporate Appeals Analyst - RN in Columbia, SC for an on-site, full-time role. You will research complex appeal requests and perform clinical reviews to determine medical necessity, documenting decisions per regulations and policies.

The ideal candidate holds an active SC RN license with 3+ years of clinical experience or 2 years clinical plus 1 year utilization/medical review, and has strong research and documentation skills.

Qualificações

• Active RN license in South Carolina.
• Strong medical terminology knowledge.
• 3 years clinical experience or 2 years clinical + 1 year utilization/medical review.

Responsabilidades

• Research complex appeal and retrospective review requests (pre-pay, post-payment, medical and pharmacy).
• Provide clinical review or benefit analysis to ensure medical necessity.
• Document decisions within mandated timeframes and regulations.
• Summarize appeal basis accurately per policies and standards.
• Research clinical information and confidentiality in line with PHI rules.
• Engage in special projects to identify quality-of-care issues.

Conhecimentos

RN License SC

Medical terminology

Claims review

Clinical experience

Research & documentation

Independent work

Formação académica

Associates Degree in Nursing

Descrição da oferta de emprego

Job Description

Job Description

Corporate Appeals Analyst - RN

Job at a Glance
Location: Columbia, South Carolina - onsite 5 days a week - 8-5
Contract: W2 only
Pay: $31.59/hour + optional medical, dental, vision, 401(k) match

Must have an active RN license in state of South Carolina and a minimum of 3 years clinical experience

Overview
This position involves researching complex appeal and retrospective review requests, including pre-pay and post-payment medical and pharmacy review appeals. The role requires thorough clinical review and benefit analysis to determine medical necessity, with documentation in compliance with regulations.

Key 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.

Required Skills

• RN License in the state of South Carolina
• Good medical terminology knowledge
• Ability to review high priority aging claims and all documentation including images and hard copies
• Clinical experience - 3 years, or 2 years clinical plus 1 year utilization/medical review, quality assurance, and home health experience
• Strong research and documentation skills
• Ability to work independently and adhere to strict deadlines

Required Education

• Associates Degree in Nursing or Graduate of Accredited School of Nursing

Preferred Skills

• Healthcare insurance experience

Why Should I Apply?
Join a team dedicated to handling high-volume workload with a focus on clinical accuracy and accountability. This role offers the opportunity to contribute to critical review processes within a supportive environment.

About CEI:
As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements.

#ZR
#INDGEN