Analyst, Appeals

Job not on LinkedIn

🔥 17 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

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Palmetto GBA

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1965

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Palmetto GBA is one of the nation's largest providers of high-volume Medicare claims and transaction processing, contact center operations, and technical services for federal healthcare programs and commercial customers. The company serves as a Medicare Administrative Contractor (MAC) and supports enrollment, claims adjudication, provider and beneficiary services, specialized programs (e. g. , DMEPOS, Home Health & Hospice, Railroad Medicare), pricing and coding analysis, and third-party administrator functions. Headquartered in Columbia, South Carolina, Palmetto GBA operates across multiple Medicare jurisdictions and is part of the Celerian Group.

📋 Description

• Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals • Perform thorough clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines • Document appeal and retrospective review decisions accurately, timely, and in compliance with applicable regulations or standards • Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures • Apply policies, procedures, clinical information, benefit provisions, and precedence to appeal and retrospective reviews • Protect confidential health information while conducting reviews • Perform special projects, including reviewing clinical information to identify quality-of-care issues • Complete approximately 8–12 weeks of training before beginning the regular shift

🎯 Requirements

• Associate's in a job related field • Graduate of Accredited School of Nursing as a degree equivalency • Four years of combined experience in clinical, utilization/medical review, quality assurance, or home health experience, including 2 years of clinical experience plus 2 years of utilization/medical review, quality assurance, or home health experience • Active, unrestricted RN license from the United States and in the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC) • Working knowledge of word processing software • Working knowledge of managed care and various forms of health care delivery systems • Strong clinical experience including home health, rehabilitation, and/or broad medical surgical experience • Knowledge of specific criteria/protocol sets • 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 • Microsoft Office proficiency • Strong computer proficiency and ability to navigate multiple systems and work across dual screens efficiently • Intermediate-level Excel skills • Experience in medical claims processing, appeals, or coding preferred • Medicare Part B experience preferred • Experience creating letters and documents by reviewing appeals and extracting information accurately preferred

🏖️ 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 • Diverse and inclusive workplace • Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs