Appeals Analyst (RN) - HealthcareLocation: Columbia, SC- Onsite (Local Candidates Only)
Schedule: Monday-Friday, 8:00 AM-5:00 PM (flexibility for an earlier start time)
Duration: 3 months with potential for extension
Pay Rate: $30 an hour
Position SummaryWe are seeking an experienced Registered Nurse (RN) to join our Appeals and Clinical Review team. This role is responsible for reviewing member and provider appeals, denials, retrospective reviews, and medical necessity determinations. The ideal candidate will have a strong clinical background, excellent critical thinking skills, and the ability to analyze medical records, benefit plans, and healthcare policies to support accurate and compliant appeal decisions.
This is a non-bedside nursing role focused on clinical documentation review, medical necessity evaluations, and healthcare coverage determinations.
Key Responsibilities- Review and evaluate medical, pharmacy, and retrospective appeal requests.
- Analyze medical records, clinical documentation, coding, and benefit coverage information.
- Determine whether denial decisions should be upheld or overturned based on clinical and contractual guidelines.
- Conduct medical necessity and benefit reviews in accordance with regulatory and organizational standards.
- Document review findings and appeal decisions accurately and within required timeframes.
- Research complex cases using clinical guidelines, policies, authorizations, and applicable regulations.
- Maintain compliance with confidentiality and protected health information (PHI) requirements.
- Participate in quality reviews and special projects related to clinical outcomes and healthcare services.
- Collaborate with internal teams to ensure consistent and compliant appeal determinations.
Required Qualifications- Active, unrestricted RN license in the state of hire or active Compact RN license.
- Associate Degree in Nursing (ADN) or graduate of an accredited nursing program.
- 3+ years of clinical nursing experience; or
- 2+ years of clinical experience plus 1 year of utilization review, medical review, quality assurance, or home health experience.
- Strong analytical and documentation skills.
- Ability to review complex medical records and make objective clinical determinations.
- Demonstrated dependability, accountability, and attention to detail.
Preferred Qualifications- Experience with healthcare insurance or managed care organizations.
- Prior experience in appeals, utilization management, case management, medical review, or claims review.
- Knowledge of medical necessity guidelines, healthcare regulations, and reimbursement processes.
Ideal Candidate- Interested in clinical review and appeals rather than direct patient care.
- Comfortable spending the majority of the day reviewing medical records and documentation.
- Able to make objective decisions based on clinical evidence, policy requirements, and healthcare regulations.
- Responsive, organized, and able to work efficiently in a fast-paced environment.
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