Remote RN Appeals Analyst - Clinical Review Expert

Palmetto GBA, LLC

Madison (WI)

Remote

USD 53,000 - 102,000

Full time

5 days ago

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Benefits offered by this job

401(k) retirement savings plan

Subsidized health plans

Life insurance

Paid annual leave

Nine paid holidays

Tuition assistance

Continuing education funds

Job summary

BlueCross BlueShield of South Carolina is seeking a nurse reviewer to research complex appeal or retrospective review requests and determine medical necessity. You will document decisions within required timeframes and ensure compliance with regulations and privacy.

This is a full-time remote role. Required are an active RN license in the United States and an Associate Degree in Nursing, with two years of clinical experience plus one year in utilization/medical review or QA, or three years

Qualifications

Associate degree in nursing or graduate of an accredited nursing program.
Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical.
Working knowledge of word processing software.
Ability to work independently, prioritize, and make sound decisions.
Knowledge of managed care and various forms of health care delivery systems.

Responsibilities

Documents the basis of the appeal or retrospective review in an accurate and timely manner in accordance with applicable regulations or standards.
Performs thorough research of the substance of service appeals based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while protecting HIPAA/privacy.
Performs appeal and retrospective reviews to determine precedence of issues in applying policies to clinical information and/or benefit provisions.
Performs special projects including reviews of clinical information to identify quality of care issues.