RN Appeals Analyst

Job not on LinkedIn

🔥 1 minute ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

💵 $53.5k - $102.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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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 or retrospective review requests, including pre-pay and post-payment review appeal requests • Provide thorough clinical review or benefit analysis to determine whether requested services meet medical necessity guidelines • Document decisions within mandated timeframes and in compliance with applicable regulations or standards • Document the basis of appeals or retrospective reviews accurately and timely • Research service appeals by members and providers using clinical documentation, contractual requirements, governing agencies, policies and procedures • Adhere to confidentiality regulations regarding protected health information • Perform appeal and retrospective reviews by determining the precedence of pertinent issues when applying policies, procedures, clinical information, benefit provisions, or policy provisions • Perform special projects, including reviews of clinical information to identify quality-of-care issues

🎯 Requirements

• Associate degree - Nursing or Graduate of Accredited School of Nursing • Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR 3 years clinical • 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) • CMS residency requirement: employees must have lived in the US for at least three out of the last five years • Preferred: three years utilization/medical review, quality assurance, or home health, plus five years clinical • Preferred: Bachelor's degree- Nursing • Preferred knowledge of Administrative Law Judge (ALJ) process, statistical principles, NCQA, URAC, SCDOI, US DOL and HIPAA standards/regulations, claims systems, and presentation skills

🏖️ Benefits

• 401(k) retirement savings plan with company match • Subsidized health plans and free vision coverage • Life insurance • Paid annual leave – the longer you work here, the more you earn • Nine paid holidays • On-site cafeterias and fitness centers in major locations • Wellness programs and healthy lifestyle premium discount • Tuition assistance • Service recognition • Incentive Plan • Merit Plan • Continuing education funds for additional certifications and certification renewal