Appeals Analyst

Job not on LinkedIn

🔥 14 hours 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 the substance of complex appeal and retrospective review requests, including pre-pay and post-payment review appeals • Conduct thorough clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines • Document decisions within mandated timeframes and in compliance with applicable regulations or standards • Document appeal or retrospective review bases accurately and timely • Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures • Adhere to confidentiality regulations regarding protected health information • Perform appeal and retrospective reviews, determining precedence of pertinent issues when applying policies, procedures, clinical information, benefits, or policy provisions • Perform special projects, including reviews of clinical information to identify quality-of-care issues • Work in a deadline-driven remote environment

🎯 Requirements

• Associate's degree in a job-related field, or graduate of an accredited school of nursing • 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 • 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 including home health, rehabilitation, and/or broad medical-surgical experience • Knowledge of specific criteria/protocol sets and their use • 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 • Microsoft Office proficiency • Full-time availability, 40 hours per week, Monday-Friday, within 8:00am-5:00pm • Position is not eligible for sponsorship now or in the future

🏖️ 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 individuals with disabilities, pregnant individuals, pregnancy-related conditions, and sincerely held religious beliefs • Benefits eligibility beginning the first of the month following 28 days of employment