Appeals Analyst

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

🎯 Requirements

• Associate's degree in a job-related field, or graduate of an accredited school of nursing • 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 including home health, rehabilitation, and/or broad medical-surgical experience • Knowledge of specific criteria/protocol sets and their use • 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 • 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) • Ability to work 40 hours per week, Monday-Friday, within 8:00am-5:00pm • Position is not eligible for sponsorship now or in the future

🏖️ 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 • Reasonable accommodations for individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs