What are the responsibilities and job description for the Analyst, Appeals position at Experis?
Job Title: Analyst, Appeals
Location: Columbia, SC
The Experis client, a leader in the healthcare industry, is seeking an Analyst, Appeals to join their clinical review department.
The ideal candidate will have strong analytical skills, excellent communication abilities, and a solid clinical background.
Key Responsibilities:
- Research complex appeal or retrospective review requests, including pre-pay and post-payment review appeal requests.
- Provide thorough clinical review or benefit analysis to determine if requested services meet medical necessity guidelines.
- Document decisions within mandated timeframes and in compliance with applicable regulations or standards.
- Perform thorough research of service appeals based on clinical documentation, contractual requirements, and policies.
- Conduct special projects, including reviews of clinical information to identify quality of care issues.
Requirements:
- Associate Degree in Nursing or Graduate of an Accredited School of Nursing.
- 2 years clinical experience plus 1 year in utilization/medical review, quality assurance, or home health.
- An active, unrestricted RN license from the United States and in the state of hire.
- Strong clinical experience, including home health, rehabilitation, or broad medical surgical experience.
- Working knowledge of managed care and various forms of healthcare delivery systems.
About Experis:
We are part of ManpowerGroup, a leading global workforce solutions company. Our expert family of brands creates substantial value for candidates and clients across more than 75 countries and territories.
Our team provides skilled talent while finding meaningful, sustainable employment for millions of people across a wide range of industries and skills.
