RN Appeals Analyst

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🔥 17 hours ago

🎸 Tennessee – Remote

🎸 Tennessee – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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CGS Administrators, LLC

WebsiteLinkedInAll Job Openings

501 - 1000 employees

⚕️ Healthcare Insurance

🤝 B2B

Healthcare Insurance • B2B • Fraud Prevention

CGS Administrators, LLC is a company that provides scalable administrative services focused on optimizing operational performance and reducing costs for health plans. With over 50 years of experience, CGS delivers a range of services including credentialing, member services, claims processing, and fraud prevention to the Centers for Medicare & Medicaid Services (CMS) and various healthcare providers. Their aim is to streamline operations and enhance customer satisfaction, contributing positively to the healthcare delivery system.

📋 Description

• 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. • 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.

🎯 Requirements

• Associate's in a job-related field • Graduate of Accredited School of Nursing • 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 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. • 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).

🏖️ Benefits

• Subsidized health plans • Dental and vision coverage • 401k retirement savings plan with company match • Life Insurance • Paid Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Education Assistance • Service Recognition • National discounts to movies, theaters, zoos, theme parks and more