RN Appeals Analyst

🔥 3 minutes ago

🏈 Alabama, Alaska, +44 more states – Remote

🏈 Alabama – Remote 🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🌺 Hawaii – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $53.5k - $102.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 0%

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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 or retrospective review requests, including pre-pay and post-payment review appeal requests • Provide thorough 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 and determine precedence of pertinent issues in applying policies, procedures, clinical information, benefits, or policy provisions • Perform special projects, including reviews of clinical information to identify quality-of-care issues

🎯 Requirements

• Associate Degree - Nursing or Graduate of Accredited School of Nursing • Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical • 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 to include home health, rehabilitation, and/or broad medical surgical experience • Knowledge of specific criteria/protocol sets and the use of the same • 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 • An 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) • CMS residency requirement for certain divisions: lived in the US for at least three out of the last five years • Preferred: Three years utilization/medical review, quality assurance, or home health, plus five years clinical • Preferred: Bachelor's degree in Nursing • Preferred knowledge of Administrative Law Judge (ALJ) process, statistical principles, NCQA, URAC, SCDOI, US DOL and HIPAA standards/regulations, claims systems, and presentation skills • Excellent organizational and time management skills

🏖️ Benefits

• 401(k) retirement savings plan with company match • Subsidized health plans and free vision coverage • Life insurance • Paid annual leave – the longer you work here, the more you earn • Nine paid holidays • On-site cafeterias and fitness centers in major locations • Wellness programs and healthy lifestyle premium discount • Tuition assistance • Service recognition • Incentive Plan • Merit Plan • Continuing education funds for additional certifications and certification renewal