Appeals Analyst

Palmetto GBA, LLC; Northern (KY); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement savings with company?

Life Insurance

Paid Time Off (PTO)

Education Assistance

Job summary

Palmetto GBA, LLC, a BlueCross BlueShield subsidiary, is seeking a full-time RN reviewer for remote workload. You will research service appeals and retrospective reviews to determine medical necessity, document decisions, and ensure compliance with regulations.

Strong nursing credentials, managed care knowledge, and attention to confidentiality are essential. Responsibilities include thorough clinical evaluation, policy application, and participation in quality projects.

Qualifications

• Associate degree or nursing graduate; RN license required.
• Experience in utilization/medical review and home health or related clinical fields preferred.
• Ability to work independently and handle confidential information with discretion.

Responsibilities

• Document the basis of appeals and retrospective reviews accurately.
• Research the substance of service appeals using clinical documentation and policies.
• Apply policies to determine precedence in clinical information for benefit decisions.
• Participate in special projects addressing quality of care issues.

Skills

Word processing

Independent work

Managed care knowledge

Clinical review experience

Knowledge of criteria/protocols

Judgment

Communication skills

Persuasion/ negotiation

Analytical thinking

HIPAA confidentiality

Education

Associate's degree in related field

Graduate of Accredited School of Nursing

Tools

Microsoft Office

Job description

### To learn more about our website privacy policy, click on this .# **Summary**# **Description****Position Purpose:** Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.**Logistics:** - one of BlueCross BlueShield's South Carolina subsidiary companies.**Location:** This is a full-time, remote (40-hours/week) working an 8hr shift Monday-Friday within the hours of 8:00am-5:00pm.**Sponsorship**: This position **is not eligible for sponsorship** now or in the future.**What You'll Do:*** Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.* Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.* Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.* Performs special projects including reviews of clinical information to identify quality of care issues.**To Qualify for This Position, You'll Need:*** **Required Education:** Associate's in a job related field+ **Degree Equivalency**: Graduate of Accredited School of Nursing* **Required Skills and Abilities:** 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.* **Required Software and Tools:** Microsoft Office.* **Required License and Certificate:** 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).**What We Prefer:*** **Preferred Education:** Bachelor's degree- Nursing.* **Preferred Work Experience:** 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.* **Preferred Skills and Abilities:** Administrative Law Judge (ALJ) process. Knowledge of statistical principles. Knowledge of National Committee for Quality Assurance (NCAG). Knowledge of Utilization Review Accreditation Commission (URAC). Knowledge of South Carolina Department of Insurance (SCDOI). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.* **Preferred Software and Other Tools:** Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.**Work Environment:** Remote. Deadline driven environment.**Our comprehensive benefits package includes the following:*** We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.* 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.**What We Can Do for You:*** We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.**What to Expect Next:*** After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.**Equal Employment Opportunity Statement**BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here'sSome states have required notifications. Here's .Palmetto GBA is a healthcare service administrator and one of the nation's largest providers of high-volume medical claims and transaction processing.We provide services and technology solutions to improve and streamline healthcare administration not only for government but also for corporate entities.We offer a wide range of services that require a diverse workforce and expansive areas of expertise from data analytics, administrative and workflow services to advanced systems.To help our associates succeed and reach their professional goal, we offer training classes and programs that help employees prepare for leadership positions and offer tuition assistance for education advancement. Palmetto GBA acknowledges associates' hard work and dedication with awards and financial incentives.