Remote RN Appeals Analyst - Clinical Review & Denials

Palmetto GBA, LLC; Provo (UT); Remote; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) retirement savings plan with公司匹

Subsidized health plans and freevision

Life insurance

Paid annual leave

Nine paid holidays

Job summary

BlueCross BlueShield of South Carolina is seeking an experienced reviewer to research and document complex appeal cases and retrospective reviews for medical necessity determinations. This remote, full-time role requires an active RN license and solid clinical experience in home health or related settings.

You will analyze clinical information, ensure compliance with regulations, and support quality assurance initiatives while handling confidential data.

Qualifications

• Associate degree in nursing or graduate of accredited nursing program.
• Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical.
• Active RN license in the United States in the state of hire or a compact multistate license.

Responsibilities

• Documents the basis of the appeal or retrospective review in accordance with regulations.
• Performs thorough research of the substance of service appeals based on clinical documentation, contracts, policies, and procedures.
• Determines precedence of issues in applying policies to clinical information and benefits.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Skills

Word processing

Independent work

Managed care

Home health experience

Clinical knowledge

Confidential data handling

Communication skills

Negotiation ability

Analytical thinking

HIPAA knowledge

NCQA knowledge

URAC knowledge

SCDOI knowledge

Education

Associate Degree - Nursing

Bachelor's degree - Nursing

Job description

BlueCross BlueShield of South Carolina is seeking an experienced reviewer to research and document complex appeal cases and retrospective reviews for medical necessity determinations. This remote, full-time role requires an active RN license and solid clinical experience in home health or related settings.

You will analyze clinical information, ensure compliance with regulations, and support quality assurance initiatives while handling confidential data.