Job Title:RN Clinical Appeals Reviewer
Employment type: Contract only, 3+ months with potential for extension
Location: Onsite in Columbia, SC.
Schedule: Monday to Friday, typically 8:00 AM to 5:00 PM, with some flexibility on start and end times
Interview: Virtual (Teams) with the hiring manager
Training: One-on-one, on-the-job
About the role
This is a clinical review position, not a traditional bedside nursing role. You will review medical records and provider and member appeals to decide whether a denial should be upheld or overturned. Day-to-day work involves reading clinical documentation, confirming appropriate coding, and applying medical necessity guidelines, contract terms and applicable regulations.
Key responsibilities
- Research complex appeal and retrospective review requests, including pre-payment and post-payment, medical and pharmacy appeals
- Review clinical documentation and benefit information to decide whether requested services meet medical necessity guidelines
- Review medical records and confirm appropriate coding to support upholding or overturning denials
- Research appeals from both members and providers using clinical documentation, contractual requirements, governing agency rules, policies, authorizations and procedures
- Identify the key issues in each case and apply policies and procedures to the clinical information and benefit provisions
- Document the basis for each decision accurately and within mandated timeframes, in line with regulations and standards
- Maintain confidentiality of protected health information (PHI)
- Support special projects, including reviews to identify quality-of-care issues
Required qualifications
- Associate Degree in Nursing, or graduate of an accredited School of Nursing
- Active, unrestricted RN license in the state of hire, or an active unrestricted multistate compact license (Nurse Licensure Compact)
- One of the following:
- 3 years of clinical experience, or
- 2 years of clinical experience plus 1 year of utilization review, medical review, quality assurance or home health experience
Preferred
- Healthcare insurance (payer) experience
What we're looking for
- Genuine interest in clinical review and appeals work (not bedside care)
- Dependability and accountability
- Strong attention to detail, research and documentation skills
- Responsive and able to move quickly through screening and interviews