Appeals Analyst

Palmetto GBA

. Research the substance of complex appeal and retrospective review requests, including pre-pay and post-payment review appeals .

Posted 10/2/2026full-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 in conducting thorough reviews of medical necessity and appeals, while adhering to confidentiality regulations and compliance standards. Proficient in utilizing analytical skills to assess clinical documentation and make informed decisions in a deadline-driven environment.

Highest-signal resume keywords

Active RN LicenseClinical Review ExpertiseManaged Care KnowledgeMicrosoft Office ProficiencyAnalytical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewBenefit AnalysisMedical Necessity GuidelinesDocumentation ComplianceQuality-of-Care ReviewConfidentiality RegulationsCriteria/Protocol KnowledgeHome Health ExperienceRehabilitation ExperienceMedical-Surgical Experience

Soft Skills

Good JudgmentCustomer Service SkillsOrganizational SkillsOral Communication SkillsWritten Communication SkillsPersuasion SkillsNegotiation SkillsIndependent Work AbilityPrioritization SkillsDecision-Making Skills

Tools & Technologies

Word Processing SoftwareMicrosoft Office

Certifications & Qualifications

Associate's DegreeRN License

Industry Keywords

Health Care Delivery SystemsAppeal RequestsRetrospective ReviewPre-Pay ReviewPost-Payment ReviewClinical DocumentationGoverning AgenciesPolicies and ProceduresProtected Health InformationNurse Licensure Compact

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Associate's degree in a job-related field, or graduate of an accredited school of nursing
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
Ability to work independently, prioritize effectively, and make sound decisions
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
Good judgment skills
Demonstrated 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
Full-time availability, 40 hours per week, Monday-Friday, within 8:00am-5:00pm
Position is not eligible for sponsorship now or in the future

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 individuals with disabilities, pregnant individuals, pregnancy-related conditions, and sincerely held religious beliefs
Benefits eligibility beginning the first of the month following 28 days of employment