Analyst – Appeals

🔥 0 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• Research the substance of complex appeal and retrospective review requests, including pre-pay and post-payment review appeals • Conduct thorough clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines • Document appeal or retrospective review decisions accurately, timely, and in compliance with applicable regulations or standards • Research member and provider service appeals using clinical documentation, contractual requirements, governing agency guidance, policies, and procedures • Adhere to confidentiality regulations regarding protected health information • Define and determine the precedence of pertinent issues when applying policies, procedures, clinical information, and benefit or policy provisions • Perform special projects, including reviews of clinical information to identify quality-of-care issues

🎯 Requirements

• Associate's in a job related field • Graduate of Accredited School of Nursing as a degree equivalency • 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 totaling four years • Working knowledge of word processing software • Working knowledge of managed care and various forms of health care delivery systems • Strong clinical experience including home health, rehabilitation, and/or broad medical surgical experience • Knowledge of specific criteria/protocol sets and their use • Good judgment, 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 • Microsoft Office proficiency • Active, unrestricted RN license from the United States and the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC) • Strongly preferred: 5 years of clinical experience • Experience in medical claims processing, appeals, or coding strongly preferred • Medicare Part B experience preferred • Strong computer proficiency, including navigating multiple systems and working across dual screens • Intermediate-level Excel skills • Experience creating letters and documents by reviewing appeals and extracting information accurately; updating departmental documents as needed

🏖️ Benefits

• Subsidized health plans, dental and vision coverage • 401k retirement savings plan with company match • Life Insurance • Paid Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Education Assistance • Service Recognition • National discounts to movies, theaters, zoos, theme parks and more • Diverse and inclusive workplace with opportunities to develop skills, advance careers and contribute to company growth