On-Site Corporate Appeals RN Analyst in Columbia, SC

CEI; Columbia (SC); On-site; USD 36,000 - 51,000; Full time

Job summary

CEI seeks a Corporate Appeals Analyst - RN for an on-site role in Columbia, SC. The position focuses on clinical review of provider and member appeals and retrospective reviews, assessing medical records and benefit criteria to decide denials within required timelines.

The ideal candidate holds an active SC RN license with 3+ years of clinical RN experience and can apply policies and regulations to clinical determinations while documenting decisions accurately.

Qualifications

• Active, unrestricted RN license (state of hire).
• 3+ years of clinical RN experience.
• Experience reviewing medical records and clinical documentation for appeals/denials.
• Ability to apply policies, procedures, and regulatory requirements to clinical determinations.
• Accurate, timely documentation of clinical decisions and rationale.
• Ability to prioritize multiple reviews and meet mandated turnaround times.

Responsibilities

• Review and analyze complex appeal and retrospective review requests (including pre-pay and post-payment).
• Evaluate clinical documentation to determine medical necessity and benefits eligibility.
• Research applicable regulations, policies, authorizations, and procedures relevant to each case.
• Assess and validate appropriate coding in support of review determinations.
• Document the basis of determinations accurately, clearly, and within mandated timeframes.
• Maintain confidentiality and comply with requirements related to protected health information.

Skills

Active RN license

Clinical experience

Medical records review

Policy compliance

Documentation accuracy

Prioritize workload

Education

Associate Degree in Nursing

Job description

CEI seeks a Corporate Appeals Analyst - RN for an on-site role in Columbia, SC. The position focuses on clinical review of provider and member appeals and retrospective reviews, assessing medical records and benefit criteria to decide denials within required timelines.

The ideal candidate holds an active SC RN license with 3+ years of clinical RN experience and can apply policies and regulations to clinical determinations while documenting decisions accurately.