Schedule: Monday-Friday, typically 8am-5pm (Some flexibility for an earlier start time)
Documents the basis of the appeal or retrospective review in an accurate and timely manner and accordance with regulations or standards.
Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements. governing agencies, policies, authorizations and procedures while adhering to confidentiality regulations regarding protected health information.
Performs appeal and retrospective reviews demonstrating the ability to define and determine the precedence of pertinent issues in applying policies and procedures to clinical information and or application to benefit or policy provisions.
Performs special projects, including reviews of clinical information to identify the quality-of-care issues
Responsibilities:
Day-to-day work will focus heavily on reviewing medical records and provider appeals/denials, confirming appropriate coding, and determining whether a denial should be upheld or overturned.
Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment, medical and pharmacy review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested. services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards
Experience:
3 years of clinical or 2 years of clinical experience plus 1 year utilization/medical review, quality assurance, and home health experience. Preferred: Healthcare insurance experience.
Skillsets:
Utilization/medical review, quality assurance, and home health experience.
Education:
Associate’s degree - Nursing or Graduate of Accredited School of Nursing.
Licenses:An active, unrestricted RN license from the US and in the state of hire OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
About US Tech Solutions: US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.
US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.
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Numbers & Facts
Location
Columbia, SC
Skills
Analysis Skillsunmatched
Clinical Informationunmatched
Clinical Medicineunmatched
Clinical Study Publicationsunmatched
Clinical Validationunmatched
Contract Requirementsunmatched
Documentationunmatched
Health Insuranceunmatched
Healthcare Providersunmatched
Home Careunmatched
Information/Data Security (InfoSec)unmatched
Medical Codingunmatched
Medical Recordsunmatched
Nursing Credentialsunmatched
Patient Care Denialsunmatched
Pharmacyunmatched
Quality Assuranceunmatched
Quality of Careunmatched
Registered Nurse (RN)unmatched
Regulationsunmatched
Time Managementunmatched
Utilization Managementunmatched
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