RN Appeals Analyst — Medical Necessity Expert

CEI; Columbia (SC); On-site; USD 56,000 - 76,000; Full time

Job summary

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.

Qualifications

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

Responsibilities

• 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.

Skills

RN License SC

Medical terminology

Claims review

Clinical experience

Research & documentation

Independent work

Education

Associates Degree in Nursing

Job description

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.