Analyst, Appeals

Palmetto GBA

. Research complex appeal and retrospective review requests, including pre-pay and post-payment reviews .

Posted 9/24/2026full-timeRemote • South Carolina • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates strong clinical expertise and analytical skills in conducting medical necessity reviews and appeals, while ensuring compliance with regulations and maintaining confidentiality of health information. Proficient in utilizing clinical documentation and policies to make informed decisions in a managed care environment.

Highest-signal resume keywords

Active RN LicenseClinical ExperienceUtilization ReviewMedical Claims ProcessingMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewBenefit AnalysisQuality AssuranceMedical Necessity DeterminationHome Health ExperienceRehabilitation ExperienceAnalytical SkillsCritical ThinkingDecision MakingKnowledge of Protocol Sets

Soft Skills

Good JudgmentCustomer ServiceOrganizational SkillsOral CommunicationWritten CommunicationPersuasionNegotiationInfluence

Tools & Technologies

Word Processing SoftwareMicrosoft OfficeExcel

Certifications & Qualifications

Associate's Degree in Related FieldGraduate of Accredited School of NursingActive Unrestricted RN License

Industry Keywords

Managed CareHealth Care Delivery SystemsMedicare Part BClinical DocumentationConfidential Health Information

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Associate's in a job related field
Graduate of Accredited School of Nursing as degree equivalency
Four years of qualifying experience: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience, or equivalent combination totaling four years
Active, unrestricted RN license from the United States and in the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact
Working knowledge of word processing software
Working knowledge of managed care and various forms of health care delivery systems
Strong clinical experience including home health, rehabilitation, and/or broad medical surgical experience
Knowledge of specific criteria/protocol sets and their use
Microsoft Office proficiency
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment, customer service, organizational, oral and written communication, persuasion, negotiation, influence, analytical, and critical-thinking skills
Ability to handle confidential or sensitive information with discretion
Preferred: 5 years of clinical experience
Preferred: experience in medical claims processing, appeals, or coding
Preferred: Medicare Part B experience
Preferred: strong computer proficiency, dual-screen workflows, intermediate Excel skills, and experience creating accurate letters and documents from appeals

Benefits

Comp & perks

Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more