Corporate Appeals Analyst - RN

Spectraforce Technologies, Inc.; Columbia (SC); On-site; USD 45,000 - 65,000; Full time

Job summary

Spectraforce Technologies, Inc. is seeking an Corporate Appeals Analyst - RN in Columbia, SC for a short-term assignment.

The role focuses on researching complex appeal requests, performing clinical reviews, and documenting medical necessity findings to support payor decisions. The ideal candidate holds an active RN license in the United States and has hands-on clinical experience along with familiarity with utilization review and healthcare policies.

Qualifications

• Active RN licensure in the United States with an unrestricted license in the state of hire.
• Minimum 2 years of clinical experience or 3 years of clinical experience plus 1 year utilization/medical review, quality assurance, and home health experience.
• Healthcare insurance familiarity preferred.

Responsibilities

• Researches complex appeal or retrospective review requests, including pre-pay and post-payment appeals.
• Provides clinical review or benefit analysis to determine medical necessity and documents decisions within required timeframes.
• Documents the basis of the appeal in accordance with regulations and standards; conducts thorough chart reviews and applies applicable policies.

Education

Associate Degree - Nursing, or Graduate of Accredited School of Nursing

Job description

Role: Corporate Appeals Analyst - RN

Location: Columbia, SC 29229

Duration: 2 months with possibility of extension

Schedule: 8am - 5:00pm - Mon - Fri

Job Description:

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.

Required Work Experience:

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

Required Education:

Associate Degree - Nursing, or Graduate of Accredited School of Nursing

Required License/Certificate:

Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC),