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Analyst, Appeals
Palmetto GBA. Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong clinical expertise and analytical skills in conducting thorough reviews of medical necessity and appeals, while ensuring compliance with regulations and maintaining confidentiality. Proficient in utilizing various healthcare delivery systems and managing documentation effectively.
Highest-signal resume keywords
Active RN LicenseClinical ExperienceUtilization ReviewMedical Claims ProcessingMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewBenefit AnalysisMedical Necessity GuidelinesQuality AssuranceHome Health ExperienceIntermediate Excel SkillsAppeals ProcessingDocumentation AccuracyCriteria/Protocol KnowledgeAnalytical Skills
Soft Skills
Customer ServiceOrganizational SkillsOral CommunicationWritten CommunicationPersuasion Skills
Tools & Technologies
Word Processing SoftwareMicrosoft OfficeDual Screen Navigation
Certifications & Qualifications
Associate's DegreeAccredited Nursing DegreeActive Compact RN License
Industry Keywords
Managed CareHealthcare Delivery SystemsMedicare Part BClinical DocumentationRegulatory Compliance
About the role
Key responsibilities & impact- 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
Requirements
What you’ll need- Associate's in a job related field
- Graduate of Accredited School of Nursing as a degree equivalency
- Four years of combined experience in clinical, utilization/medical review, quality assurance, or home health experience, including 2 years of clinical experience plus 2 years of utilization/medical review, quality assurance, or home health experience
- 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 (NLC)
- 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
- Customer service, organizational, oral and written communication skills
- Ability to persuade, negotiate, or influence others
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- Microsoft Office proficiency
- Strong computer proficiency and ability to navigate multiple systems and work across dual screens efficiently
- Intermediate-level Excel skills
- Experience in medical claims processing, appeals, or coding preferred
- Medicare Part B experience preferred
- Experience creating letters and documents by reviewing appeals and extracting information accurately preferred
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
- Diverse and inclusive workplace
- Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs