RN Appeals Analyst (W@H TN)

To Qualify for This Position, You'll Need the Following: Required Education: Associate's in a job-related field Degree Equivalency: Graduate of Accredited School of Nursing Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years. Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Good judgment skills. Demonstrated customer service, organizational, oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. Required License and Certificate: An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). We Prefer That You Have the Following: Preferred Education: Bachelor's degree- Nursing. Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical. Preferred Skills and Abilities: Administrative Law Judge (ALJ) process. Knowledge of statistical principles. Knowledge of the National Committee for Quality Assurance (NCAG). Knowledge of Utilization Review Accreditation Commission (URAC). Knowledge of South Carolina Department of Insurance (SCDOI). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills. Preferred Software and Other Tools: Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.

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