Analyst, Appeals

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🔥 8 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🧐 Analyst

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Palmetto GBA

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1965

⚕️ Healthcare Insurance

🏛️ Government

🤝 B2B

Healthcare Insurance • Government • B2B

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

• 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

• Required Education: Associate's in a job related field • Degree Equivalency : Graduate of Accredited School of Nursing • Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. • Required Skills and Abilities: 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. • Required Software and Tools : Microsoft Office. • Required License and Certificate: 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