Altum Solutions Appeals Analyst Cayce, SC · Full time

We are currently seeking a dedicated and analytical Registered Nurse for the role of Analyst, Appeals. The chosen candidate will be integral in handling complex appeal or retrospective review requests within the framework of medical necessity guidelines and applicable regulations.


Key Responsibilities:

  • Clinical Review (35%): Documenting the basis of appeal or retrospective reviews accurately within mandated timeframes.
  • Research and Analysis (30%): Conducting detailed research on the substance of service appeals based on clinical documentation, policy procedures, and confidentiality regulations.
  • Appeal and Retrospective Reviews (30%): Performing reviews, applying policies and procedures critically to clinical information, and ensuring compliance with benefit or policy provisions.
  • Special Projects (5%): Engaging in reviews of clinical information to identify quality of care issues.

Required Qualifications:

  • Associate Degree in Nursing or Graduate of Accredited School of Nursing.
  • Active, unrestricted RN license in the United States and the state of South Carolina or active compact multistate unrestricted RN license.
  • 2+ years of clinical experience and 1+ year(s) in utilization/medical review, quality assurance, or home health.
  • Proficiency in Microsoft Office and the ability to work independently with strong decision-making skills.

Preferred Qualifications:

  • Bachelor's degree in Nursing.
  • 3+ years of utilization/medical review, quality assurance, or home health experience and 5+ years clinical experience.
  • Knowledge of NCQA, URAC, SCDOI, US DOL, and HIPAA standards/regulations.
  • Exceptional organizational, time management, and presentation skills.


  • Expertise in claims processing, clinical documentation, and clinical review.
  • Demonstrated customer service orientation with excellent communication skills.
  • Proficient in Microsoft Excel, Word, and other Office applications.


Location: Columbia, SC

Duration: 11/27/23 - 3/3/24

Hours per week: 40


$35 - $39 per hour