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Appeals Analyst
Columbia, SC
Job Description
Job Title: RN Appeals Analyst
Location: Columbia, SC. 29229 (Remote, after 4 weeks onsite training)
Duration: 3 months assignment (Possible Temp to perm)
Shift: Mon - Fri, 8:30 am to 5 pm.
Summary:
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.
Responsibilities:
Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. 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 License and Certificate: 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).
Preferred Education: Bachelor's degree in nursing.
Preferred Work Experience: 3 years utilization/medical review, quality assurance, or home health, plus 5 years clinical.
Languages: English.
SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at nahr@spectraforce.com if you require reasonable accommodation.
Location: Columbia, SC. 29229 (Remote, after 4 weeks onsite training)
Duration: 3 months assignment (Possible Temp to perm)
Shift: Mon - Fri, 8:30 am to 5 pm.
Summary:
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.
Responsibilities:
- 35% Document the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
- 30% 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.
- 30% Performs appeal and retrospective reviews demonstrating the ability to define and determine the precedence of pertinent issues in the application of policies and procedures to clinical information and or application to benefit or policy provisions.
- 5% Performs special projects including reviews of clinical information to identify quality of care issues.
Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. 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 License and Certificate: 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).
Preferred Education: Bachelor's degree in nursing.
Preferred Work Experience: 3 years utilization/medical review, quality assurance, or home health, plus 5 years clinical.
Languages: English.
SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at nahr@spectraforce.com if you require reasonable accommodation.
Job Summary
Company
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Associate Degree
Required Experience
2+ years
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