Analyst, Appeals

Palmetto GBA hires an Analyst, Appeals to research complex appeals and retrospective review requests. The role conducts clinical reviews or benefit analyses to assess medical necessity and documents decisions within required timeframes and in compliance with applicable regulations and standards.

Responsibilities

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable 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 and procedures, while adhering to confidentiality regulations regarding protected health information
• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions
• Performs special projects including reviews of clinical information to identify quality of care issues

Preferred

• 5 years of clinical experience
• Experience in medical claims processing, appeals, or coding
• Medicare Part B experience
• Strong computer proficiency, with the ability to navigate multiple systems and work across dual screens efficiently
• Intermediate-level Excel skills
• Experience creating letters and documents by reviewing appeals and extracting information with a high degree of accuracy; updates departmental documents as needed
• Medical Claims Processing
• Appeals Processing
• Medical Coding
• Medicare Part B
• Multiple-System Navigation
• Dual-Screen Proficiency
• Excel
• Letter
• Document Creation
• Appeal Review
• Information Extraction
• Document Maintenance
• Attention to Detail

Benefits

• Fully remote work environment
• Eligible to participate in the benefits the first of the month following 28 days of employment: subsidized health plans, dental and vision coverage
• Eligible to participate in the benefits the first of the month following 28 days of employment: 401k retirement savings plan with company match
• Eligible to participate in the benefits the first of the month following 28 days of employment: life insurance
• Eligible to participate in the benefits the first of the month following 28 days of employment: paid time off (PTO)
• Eligible to participate in the benefits the first of the month following 28 days of employment: on-site cafeterias and fitness centers in major locations
• Eligible to participate in the benefits the first of the month following 28 days of employment: education assistance
• Eligible to participate in the benefits the first of the month following 28 days of employment: service recognition
• Eligible to participate in the benefits the first of the month following 28 days of employment: national discounts to movies, theaters, zoos, theme parks and more

Company

• Health insurer and government contract administrator
• Columbia, South Carolina, USA
• https://www.southcarolinablues.com/
• Founded in 1946
• 10001+ employees

Qualifications

• Associate's in a job related field
• Graduate of Accredited School of Nursing
• 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years
• Working knowledge of word processing software
• Ability to work independently, prioritize effectively, and make sound decisions
• 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
• Good judgment skills
• Demonstrated customer service, organizational, oral and written communication skills
• Ability to persuade, negotiate, or influence others
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion
• Microsoft Office
• An active, unrestricted RN license 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)
• 5 years of clinical experience
• Experience in medical claims processing, appeals, or coding
• Medicare Part B experience
• Strong computer proficiency, with the ability to navigate multiple systems and work across dual screens efficiently
• Intermediate-level Excel skills
• Experience creating letters and documents by reviewing appeals and extracting information with a high degree of accuracy; updates departmental documents as needed
• 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years.

Required skills

• Home Health, Managed Care, Medical Appeals, Medical Claims Processing, Medical Coding, Medical Review, Medical-Surgical Nursing, Medicare Part B, Microsoft Excel, Microsoft Office, Rehabilitation, Unrestricted RN License, Utilization Review

Preferred skills

• 5 years of clinical experience, Experience in medical claims processing, appeals, or coding, Intermediate-level Excel skills, Medicare Part B experience

Experience

• 4+ years