South Carolina Licensed Appeals Analyst

Job Summary

Researching complex appeal requests, the full-time South Carolina Licensed Appeals Analyst will provide clinical reviews and benefit analyses in a remote environment, ensuring compliance with medical necessity guidelines and documentation standards.

Key responsibilities

• Documents the basis of appeals and retrospective reviews accurately and timely in accordance with regulations
• Conducts thorough research on service appeals based on clinical documentation and contractual requirements
• Performs special projects to identify quality of care issues through clinical information reviews

Required qualifications

• Associate's degree in a job-related field or a graduate of an accredited School of Nursing
• 2 years of clinical experience plus 1 year in utilization/medical review or quality assurance, or 3 years of clinical experience
• Active, unrestricted RN license from the United States or a compact multistate unrestricted RN license
• Working knowledge of Microsoft Office and ability to navigate multiple systems efficiently
• Strong clinical experience, preferably in home health or medical surgical environments