Healthcare Appeals Analyst, RN

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🔥 6 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $71.2k - $89k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🧐 Analyst

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GuideWell Source

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

GuideWell Source is a company within the GuideWell Family that focuses on accelerating innovative health solutions to market, transforming and reshaping the health industry. It specializes in healthcare delivery, providing new models and superior outcomes for patients. The company emphasizes consumerism in healthcare, engaging clients in meaningful ways. GuideWell Source offers healthcare insurance, protecting employers and consumers with coverage plans and services. The company also provides administrative and claims processing services for state and federal Medicare and Medicaid programs, establishing itself as a trusted business partner in the healthcare sector with a focus on operational excellence.

📋 Description

• Review and research provider appeals to reach final determinations • Review provider appeals and medical documentation • Review CMS-1500 forms or equivalent electronic counterparts for proper coding • Access Legacy or Diamond to review how claims were originally processed by BCBSF • Assist appeal coordinators with clinical research and appeal processing under ERISA, HIPAA, and corporate and departmental standards • Interpret BCBSF Medical Coverage Guidelines for staff • Collaborate with the Managing Medical Director to facilitate changes to medical coverage guidelines • Research, prepare, and present clinical appeal cases to the Provider Appeal Panel • Gather data from business partners across the organization for final determinations • Follow regulatory requirements, corporate values, policies, and procedures • Ensure final determinations are reached and communicated to providers within strict timelines • Document findings and final determinations in BCBSF systems and SQL databases • Author statements in final provider documents supporting the final determination

🎯 Requirements

• 2+ years of related clinical work experience • Related bachelor's degree or additional related equivalent work experience • Active RN state licensure and/or compact state licensure • Florida licensed Registered Nurse • Extensive experience with Medical Coverage Guidelines concerning medical necessity and experimental/investigational procedures • Ability to interact professionally with internal and external customers • Ability to simultaneously use multiple research and processing systems • Knowledge of HIPAA and ERISA requirements • Knowledge of regulatory requirements • Ability to work within strict timeframes • Proficiency with Microsoft Office, including Word, PowerPoint, and Excel • Occasional travel may be required to support business operations

🏖️ Benefits

• Medical, dental, vision, life and global travel health insurance • Income protection benefits: life insurance, short- and long-term disability programs • Leave programs to support personal circumstances • Retirement Savings Plan including employer match • Paid time off • Volunteer time off • 10 holidays • 2 well-being days • Additional voluntary benefits • Comprehensive wellness program • Opportunities for incentive or commission compensation • Regular annual reviews with pay for performance considerations for base pay increases