South Carolina Licensed Appeals Analyst

Job Summary

Working remotely on a full-time basis, the South Carolina Licensed Appeals Analyst will research complex appeal requests, perform clinical reviews, and document decisions in compliance with regulations.

Key responsibilities:

• Conduct thorough research on service appeals based on clinical documentation and regulatory requirements
• Document the basis of appeals accurately and within mandated timeframes
• Perform retrospective reviews to determine adherence to medical necessity guidelines

Required qualifications:

• Associate's degree in a job-related field or a graduate of an accredited school of nursing
• Two years of clinical experience plus two years in utilization/medical review, quality assurance, or home health, totaling four years of relevant experience
• Active, unrestricted RN license in the state of hire or an active compact multistate unrestricted RN license
• Strong clinical background in home health, rehabilitation, or broad medical surgical experience
• Proficiency in Microsoft Office and ability to handle confidential information with discretion