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Medical Appeals Analyst (33248992)
Columbia, SC
Job 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 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.
Required Skills and Abilities: Working knowledge of word processing software. 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. Analytical or critical thinking skills.
Required Software and Tools: Microsoft Office.
Preferred Skills and Abilities: Administrative Law Judge (ALJ) process. Knowledge of statistical principles. Knowledge of National Committee for Quality Assurance (NCAG). Knowledge of Utilization Review Accreditation Commission (URAC). Knowledge of South Carolina Department of Insurance (SCDOI). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.
Required Education: Associate Degree - Nursing or 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 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).
Preferred Education: Bachelor's degree- Nursing. Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.
It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following:
• Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status
• Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment
• Denial of family or medical care leave
• Use of a guide or support animal
• Military or veteran status
• Political activities or affiliations
• Exercise of civil rights
• Domestic violence, assault, or stalking victim status
• GED certificate
• Arrest, expunged, or sealed records
• Application for or enrollment in Medi-Cal
• Status as a smoker or non-smoker
• Credit report or credit information
• Child or spousal support withholding
• Wage garnishment for consumer debt
• Relationship with someone with a disability
• Lawful conduct occurring during nonworking hours not on Company premises
• Any other protected class, in accordance with applicable federal, state, and local laws
Discriminatory, harassing, or retaliatory behavior is prohibited from coworkers, supervisors, managers, owners, and third parties, including clientele. The Company takes allegations of discrimination, harassment and retaliation very seriously and will promptly conduct an investigation when warranted. Equal employment opportunity includes, but is not limited to, employment, training, promotion, demotion, transfer, leaves of absence and termination.
Required Skills and Abilities: Working knowledge of word processing software. 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. Analytical or critical thinking skills.
Required Software and Tools: Microsoft Office.
Preferred Skills and Abilities: Administrative Law Judge (ALJ) process. Knowledge of statistical principles. Knowledge of National Committee for Quality Assurance (NCAG). Knowledge of Utilization Review Accreditation Commission (URAC). Knowledge of South Carolina Department of Insurance (SCDOI). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.
Required Education: Associate Degree - Nursing or 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 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).
Preferred Education: Bachelor's degree- Nursing. Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.
It is the policy of the Company to provide equal employment opportunities to all qualified individuals and to administer all aspects and conditions of employment without regard to the following:
• Race and associated traits, including hairstyle; Color, Age, Sex, Sexual orientation, Gender, Gender identity and gender expression; Religion, including dress and grooming practices; National origin, including language use restrictions; Pregnancy, childbirth, or breastfeeding; Marital or familial status; Genetic information, including family medical history; Physical or mental disability; Citizenship and/or immigration status
• Medical conditions, including cancer, AIDS/HIV, and occupational pneumoconiosis without respiratory impairment
• Denial of family or medical care leave
• Use of a guide or support animal
• Military or veteran status
• Political activities or affiliations
• Exercise of civil rights
• Domestic violence, assault, or stalking victim status
• GED certificate
• Arrest, expunged, or sealed records
• Application for or enrollment in Medi-Cal
• Status as a smoker or non-smoker
• Credit report or credit information
• Child or spousal support withholding
• Wage garnishment for consumer debt
• Relationship with someone with a disability
• Lawful conduct occurring during nonworking hours not on Company premises
• Any other protected class, in accordance with applicable federal, state, and local laws
Discriminatory, harassing, or retaliatory behavior is prohibited from coworkers, supervisors, managers, owners, and third parties, including clientele. The Company takes allegations of discrimination, harassment and retaliation very seriously and will promptly conduct an investigation when warranted. Equal employment opportunity includes, but is not limited to, employment, training, promotion, demotion, transfer, leaves of absence and termination.
Job Summary
Start Date
As soon as possible
Employment Term and Type
Regular, Full Time
Required Education
Associate Degree
Required Experience
2+ years
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