Duration: 3 Months Contract
Job Description:- Hour/Schedule: Monday-Friday, typically 8am-5pm.
- Training - "One on One" | On-the-job.
- Typical day: Day-to-day work will focus heavily on reviewing medical records and provider appeals/denials, confirming appropriate coding, and determining whether a denial should be upheld or overturned.
- Looking for candidates who demonstrate dependability and accountability.
Responsibilities:- Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment, medical and pharmacy 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.
- Documents the basis of the appeal or retrospective review in an accurate and timely manner and accordance with 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, authorizations and procedures while adhering to confidentiality regulations regarding protected health information.
- Performs appeal and retrospective reviews demonstrating the ability to define and determine the precedence of pertinent issues in applying policies and procedures to clinical information and or application to benefit or policy provisions.
- Performs special projects, including reviews of clinical information to identify the quality-of-care issues.
Experience:- 3 years of clinical or 2 years of clinical experience plus 1 year utilization/medical review, quality assurance, and home health experience.
Skillsets:- Working knowledge of word processing software.
- Knowledge of quality improvement processes and demonstrated ability with these activities.
- Knowledge of contract language and application.
- Ability to work independently, prioritize effectively, and make sound decisions.
- Good judgment skills.
- Demonstrated customer service, organizational, and presentation skills.
- Demonstrated 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.
Education:- Associate Degree - Nursing.
Additional Qualifications:- Licenses: Active SC unrestricted RN licensure
- Shift Hours: Monday through Friday, 8:00AM-5:00PM
About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit
www.ustechsolutions.com.
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.
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