Remote RN Appeals Analyst — Clinical Review Expert

BlueCross and BlueShield of South Carolina; États-Unis; À distance; USD 53 000 - 102 000; Plein temps

Avantages offerts par ce poste

401(k) plan

Health plans

Life insurance

Paid annual leave

9 paid holidays

On-site cafeterias

Wellness programs

Tuition assistance

Recognition programs

Incentive plan

Merit plan

Continuing education funds

Résumé du poste

BlueCross BlueShield of South Carolina is seeking a nurse to research the substance of complex appeal requests, perform clinical review to determine medical necessity, and document decisions within required timeframes.

This full-time remote role (40 hours/week, 8 a.m.–5 p.m. local time) requires an active RN license in the United States, CMS residency constraints, and strong analytical, communication, and confidentiality skills.

Qualifications

• Associate degree - Nursing or graduate of accredited nursing program.
• An active RN license in the United States.
• Experience in utilization/medical review or home health is preferred.

Responsabilités

• Document basis of appeal or retrospective review accurately and timely.
• Perform clinical research of service appeals based on documentation and policies.
• Determine precedence of issues when applying policies to medical information.
• Lead special projects reviewing quality of care.

Connaissances

Word processing

Independent work

Prioritization

Decision making

Managed care

Clinical experience

Communication skills

Confidentiality

Negotiation

Analytical thinking

Formation

RN/Associate degree

Description du poste

BlueCross BlueShield of South Carolina is seeking a nurse to research the substance of complex appeal requests, perform clinical review to determine medical necessity, and document decisions within required timeframes.

This full-time remote role (40 hours/week, 8 a.m.–5 p.m. local time) requires an active RN license in the United States, CMS residency constraints, and strong analytical, communication, and confidentiality skills.