Altum Solutions Appeals Analyst Cayce, SC · Full time

Apply for Appeals Analyst

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.

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.

Schedule:

Location: Columbia, SC

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

Hours per week: 40