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RN Appeals Analyst (32697442)

Professional Management Enterprises
United States, South Carolina, Columbia
April 15, 2024
Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment 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. Schedule is M-F 8:00am - 5:00pm. Skills: Working knowledge of word processing software. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Administrative Law Judge (ALJ) process. Statistical principles. National Committee for Quality Assurance (NCAG). Utilization Review Accreditation Commission (URAC). South Carolina Department of Insurance (SCDOI). US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Knowledge of claims systems. Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing. Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. Required License and Certificate: An active, unrestricted RN license in the state of SC, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). Preferred Education: Bachelor's degree- Nursing. Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.