Remote Appeals Analyst: Clinical Review & Policy Insight

Palmetto GBA, LLC; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

Palmetto GBA, LLC—a BlueCross BlueShield South Carolina subsidiary—seeks a remote RN reviewer to analyze complex appeal and retrospective review requests for medical necessity. You will document decisions within regulatory timelines, perform thorough research across documents, and apply policy provisions to clinical information.

This full-time remote role requires strong clinical experience and knowledge of managed care.

Qualifications

• Associate degree in a related field required.
• Graduate of Accredited School of Nursing or equivalent degree equivalency.
• Active RN license in the United States in the state of hire or active compact multistate license.

Responsibilities

• Document basis of the appeal or retrospective review accurately and timely.
• Research substance of service appeals using clinical docs, contracts and policies.
• Apply policies to clinical information to determine precedence in decisions.
• Conduct special projects reviewing clinical information for quality of care issues.

Skills

Word processing

Analytical thinking

Communication skills

Decision making

Customer service

Education

Associate degree in related field

Nursing degree equivalency

Tools

Microsoft Office

Job description

Palmetto GBA, LLC—a BlueCross BlueShield South Carolina subsidiary—seeks a remote RN reviewer to analyze complex appeal and retrospective review requests for medical necessity. You will document decisions within regulatory timelines, perform thorough research across documents, and apply policy provisions to clinical information.

This full-time remote role requires strong clinical experience and knowledge of managed care.