Ourhrconnect
Analyst, Appeals
US · W@H South Carolina · Remote · Full-time · Mid
需配合美国东部时间（8:00 a.m. - 4:30 p.m.）的工作时间，可选择6:00 a.m.开始的班次
Salary not stated
AI summary
About the company
Palmetto GBA是蓝十字蓝盾的南卡罗来纳州子公司，从事医疗相关服务，为员工提供多元化包容的工作环境。
Role overview
该全职远程岗位隶属于蓝十字蓝盾南卡罗来纳州子公司Palmetto GBA，主要负责复杂申诉或回顾性审查请求的研究、临床审查与福利分析，确保服务符合医疗必要性指南，按规定时限完成决策文档，需配合美国东部时间工作，培训周期约8-12周。
Responsibilities
- 准确及时记录申诉或回顾性审查的依据，符合法规标准
- 基于临床文档等研究服务申诉内容，遵守隐私法规
- 开展申诉与回顾性审查，应用政策程序判定相关问题
- 参与特殊项目，审查临床信息识别医疗质量问题
Requirements
- 相关领域副学士学位，或护理学校毕业
- 2年临床经验+2年利用/医疗审查等经验，或总计4年相关经验
- 持有美国无限制RN执照或NLC多州RN执照
- 掌握文字处理软件，具备独立工作与决策能力
- 了解管理式医疗与医疗服务提供系统
- 具备临床经验，掌握相关标准协议与Excel技能
- 具备良好判断、沟通、谈判与分析能力，能处理机密信息
Nice to have
- 5年临床经验
- 有医疗理赔处理、申诉或编码经验
- 有Medicare Part B经验
- 具备中级Excel技能，能高效操作多系统
- 有创建申诉相关文档的经验
Pay & benefits
- 入职28天后可参与福利计划
- 补贴型医疗、牙科和视力保险
- 含公司匹配的401k退休计划
- 人寿保险、带薪休假
- 主要地点有现场食堂和健身中心
- 教育援助、服务认可及各类折扣
Hiring process & how to apply
- 提交申请后招聘团队审核简历
- 可能进行简短电话面试或邮件沟通验证简历
Notes for China-based candidates
- 该岗位为美国远程全职岗位，需持有美国RN执照或NLC多州RN执照
- 需配合美国东部时间工作，无法远程调整时区
- 结算相关以美国雇主规定为准，需遵守美国医疗相关法规
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Excerpt
Summary Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within…
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