RN Appeals Analyst – SC, GA

🔥 0 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 10%

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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 • Perform clinical review or benefit analysis to determine whether requested services meet medical necessity guidelines • Document decisions within mandated timeframes and in compliance with applicable regulations or standards • Document the basis of appeals or retrospective reviews accurately and timely • Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures • Adhere to confidentiality regulations regarding protected health information • Perform appeal and retrospective reviews by 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

• Associates in a job-related field • Graduate of Accredited School of Nursing • 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 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 • Microsoft Office proficiency • 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) • Ability to work independently, prioritize effectively, and make sound decisions • Good judgment, analytical or critical thinking, customer service, organizational, oral and written communication skills • Ability to persuade, negotiate, or influence others • Ability to handle confidential or sensitive information with discretion

🏖️ 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