Palmetto GBA

Content Writer

• Create reports according to user information and specifications
• Maintain and revise programming logic for existing routine reports to ensure timely and accurate data
• Analyze current reporting methodologies
• Create and maintain computer- and web-based systems for data retrieval
• Generate routine internal and external reports daily, monthly, quarterly, and annually
• Interview customers to obtain criteria for requested data
• Add and update programming logic according to customer specifications and requirements
• Assist with system testing and provide technical support
• Assist with departmental training issues
• Participate on project teams to develop, maintain, and implement new processes, applications, policies, and forms

Senior Database Report Writer – Analyst

Analyst

• 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

Appeals Analyst

• Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals
• Perform thorough clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines
• Document appeal and retrospective review decisions accurately, timely, and in compliance with applicable regulations or standards
• Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures
• Apply policies, procedures, clinical information, benefit provisions, and precedence to appeal and retrospective reviews
• Protect confidential health information while conducting reviews
• Perform special projects, including reviewing clinical information to identify quality-of-care issues
• Complete approximately 8–12 weeks of training before beginning the regular shift

Analyst, Appeals

• Research complex appeal and retrospective review requests, including pre-pay and post-payment reviews
• Conduct clinical reviews or benefit analyses to determine medical necessity
• Document appeal and retrospective review decisions accurately, promptly, and in compliance with regulations and standards
• Research member and provider service appeals using clinical documentation, contractual requirements, governing-agency guidance, policies, and procedures
• Apply policies, procedures, benefit provisions, and clinical information to determine pertinent issues and precedence
• Protect confidential health information
• Perform special projects, including reviewing clinical information to identify quality-of-care issues

General

• Maintain records and process claims in medical review.
• Process ingoing and outgoing mail and prepare work for nursing staff.
• Troubleshoot claims before and after nurse review.
• Monitor claims-processing timeliness and adjust incorrectly keyed claims.
• Process claim denials and adjustment claims for pre-pay and post-pay departments.
• Investigate and analyze adjustment claim history and denial records.
• Prescreen records for review and maintain accurate claim records.
• Communicate with providers and assist the provider service department with inquiries.
• Generate educational correspondence to providers regarding denials.
• Perform quality control of work processes.
• Assist the manager with special projects.
• Work onsite Monday-Friday, 8:00-4:30, with minimal phone contact.

Technical Information Specialist

Medical Reviewer

• Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
• Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
• Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement eligibility
• Monitor process timeliness according to contractor standards
• Document medical rationale supporting payment or denial of services and supplies
• Educate internal and external staff on medical reviews, terminology, coverage determinations, and coding procedures
• Participate in quality-control activities supporting corporate and team objectives
• Provide guidance, direction, and input to LPN team members
• Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties assigned by management
• Complete six-week paid training, including one onsite week and five remote weeks

Medical Reviewer II

Clerk

• Assist management with planning, coordination, and assignment of work across staff
• Train new staff and assist staff with proper processing methods
• Assemble and distribute electronic and hard copy claims to support staff
• Screen, code, and key claims to support proper and accurate adjudication
• Process edits and resolve errors through claims editing software
• Collect, sort, and deliver completed claims to the appropriate area
• Document errors and other important information throughout claims processing
• Assist support staff with questions throughout processing

Lead Claims Clerk

• Process denials of claims
• Process adjustment claims for pre-pay and post-pay departments
• Investigate and analyze adjustment claim history and denial records
• Prescreen records for review and maintain accurate claim records
• Communicate with providers and assist the provider service department with inquiries
• Generate educational correspondence to providers regarding denials
• Perform quality control of work processes
• Assist the manager with special projects
• Maintain records and process claims in medical review
• Process incoming and outgoing mail and prepare work for nursing staff
• Troubleshoot claims before and after nurse review
• Monitor claims-processing timeliness and adjust incorrectly keyed claims

Senior Database Report Writer – Analyst

Appeals Analyst

Analyst, Appeals

Analyst, Appeals

Technical Information Specialist

Medical Reviewer II

Lead Claims Clerk

Information Technology Specialist