Corporate Appeals Analyst - RN
Job at a Glance
- Title: Corporate Appeals Analyst - RN
- Location: Columbia, SC (On-site 5 days a week, 8-5)
- Contract: W2 only
- Pay: $31.59/hour andoptional medical, dental, vision, 401(k) match
- Must have an active, unrestricted RN license in the state of South Carolina and 3+ years clinical RN experience
Overview
This on-site role focuses on clinical review of complex provider and member appeals and retrospective reviews. You will analyze medical records and benefit/policy criteria to determine whether denials should be upheld or overturned while meeting required timelines and compliance standards.
Key Responsibilities
- Review and analyze complex appeal and retrospective review requests (including pre-pay and post-payment).
- Evaluate clinical documentation to determine medical necessity and benefits eligibility.
- Research applicable regulations, policies, authorizations, and procedures relevant to each case.
- Assess and validate appropriate coding in support of review determinations.
- Document the basis of determinations accurately, clearly, and within mandated timeframes.
- Maintain confidentiality and comply with requirements related to protected health information.
- Support special projects, including identification of potential quality-of-care issues.
Required Skills
- Active, unrestricted RN license (state of hire) OR active compact multistate RN license (NLC).
- 3 years of clinical experience, OR 2 years clinical experience plus 1 year in utilization/medical review, quality assurance, and home health.
- Experience reviewing medical records and clinical documentation for appeals/denials.
- Ability to apply policies, procedures, and regulatory requirements to clinical determinations.
- Accurate, timely documentation of clinical decisions and rationale.
- Ability to prioritize multiple reviews and meet mandated turnaround times.
Education
- Associate Degree in Nursing or graduate of an accredited school of nursing.
Preferred Skills
- Healthcare insurance experience.
- Experience with benefit analysis related to coverage determinations.
- Experience supporting or identifying quality-of-care issues during clinical reviews.
Why Should I Apply?
If you are an RN who enjoys analytical, documentation-driven clinical work, this role offers the opportunity to apply your expertise to appeals and retrospective reviews in a structured, compliance-focused environment.
About CEI:
As a trusted technology partner, CEI delivers solutions that help our customers transform their business and achieve meaningful results. From strategy and custom application development through application management - our technology and digital experience services are tailored to meet each unique need of our customers. Our staffing solutions bring specialized skills to complement our customers' workforce and project requirements.
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