RN Appeals Analyst — Medical Review Expert

CEI; Columbia (SC); On-site; USD 34,000 - 49,000; Full time

Job summary

CEI in Columbia, SC is seeking an experienced Registered Nurse to join the Appeals and Clinical Review team as an Appeals Analyst (RN). This on-site role reviews member and provider appeals, denials, retrospective reviews, and medical necessity determinations.

The ideal candidate will hold an active RN license, ADN or nursing program graduate, and 3+ years of clinical experience (or 2+ years plus 1 year in utilization/medical review).

Qualifications

• Active, unrestricted RN license in the state of hire.
• ADN or nursing program graduate.
• 3+ years of clinical nursing experience; or 2+ years of clinical experience plus 1 year of utilization review, medical review, quality assurance, or home health experience.
• Strong analytical and documentation skills.
• Ability to review complex medical records and make objective clinical determinations.
• Demonstrated dependability, accountability, and attention to detail.

Responsibilities

• Review and evaluate medical, pharmacy, and retrospective appeal requests.
• Analyze medical records, clinical documentation, coding, and benefit coverage information.
• Determine whether denial decisions should be upheld or overturned based on clinical and contractual guidelines.
• Conduct medical necessity and benefit reviews in accordance with regulatory and organizational standards.
• Document review findings and appeal decisions accurately and within required timeframes.
• Research complex cases using clinical guidelines, policies, authorizations, and applicable regulations.
• Maintain compliance with confidentiality and protected health information (PHI) requirements.
• Participate in quality reviews and special projects related to clinical outcomes and healthcare services.
• Collaborate with internal teams to ensure consistent and compliant appeal determinations.

Skills

Analytical skills

Documentation skills

Education

ADN or nursing program graduate

Job description

CEI in Columbia, SC is seeking an experienced Registered Nurse to join the Appeals and Clinical Review team as an Appeals Analyst (RN). This on-site role reviews member and provider appeals, denials, retrospective reviews, and medical necessity determinations.

The ideal candidate will hold an active RN license, ADN or nursing program graduate, and 3+ years of clinical experience (or 2+ years plus 1 year in utilization/medical review).