Corporate Appeals Analyst - RN

Job at a Glance
Location: Columbia, South Carolina - onsite 5 days a week - 8-5
Contract: W2 only
Pay: $31.59/hour + optional medical, dental, vision, 401(k) match

Must have an active RN license in state of South Carolina and a minimum of 3 years clinical experience 

Overview
This position involves researching complex appeal and retrospective review requests, including pre-pay and post-payment medical and pharmacy review appeals. The role requires thorough clinical review and benefit analysis to determine medical necessity, with documentation in compliance with regulations.

Key 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.

Required Skills

• RN License in the state of South Carolina
• Good medical terminology knowledge
• Ability to review high priority aging claims and all documentation including images and hard copies
• Clinical experience - 3 years, or 2 years clinical plus 1 year utilization/medical review, quality assurance, and home health experience
• Strong research and documentation skills
• Ability to work independently and adhere to strict deadlines

Required Education

• Associates Degree in Nursing or Graduate of Accredited School of Nursing

Preferred Skills

• Healthcare insurance experience

Why Should I Apply?
Join a team dedicated to handling high-volume workload with a focus on clinical accuracy and accountability. This role offers the opportunity to contribute to critical review processes within a supportive environment.

About CEI:
As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements.

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