Remote RN Appeals Analyst - Clinical Review Expert

Palmetto GBA, LLC; United States; Remote; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) match

Health plans

Life insurance

Paid annual leave

Nine paid holidays

Tuition assistance

Job summary

BlueCross BlueShield of South Carolina seeks an experienced nurse reviewer to adjudicate appeals and retrospective reviews for medical necessity. This full-time remote role supports Mondays–Fridays, 8:00am–5:00pm, with a strong emphasis on accurate documentation and privacy.

The ideal candidate has RN licensure in the US, clinical and utilization review experience, and the ability to analyze complex records while communicating decisions clearly.

Qualifications

• Associate degree in Nursing or graduate of accredited school of nursing (RN).
• Twoyears clinical experience plus one year utilization/medical review, quality assurance, or home health, OR 3 years clinical.
• Active, unrestricted RN license in the US or active compact multistate license as defined by NLC.

Responsibilities

• Documents the basis of the appeal or retrospective review in an accurate and timely manner per regulations or standards.
• Performs thorough research of service appeals by member and provider using clinical documentation, contracts, and policies, while protecting PHI.
• Executes appeal and retrospective reviews, applying policies to clinical information and benefit provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Skills

RN licensure

Clinical review

Utilization review

Research & analysis

Communication skills

Confidential information handling

Independent working

Word processing

Decision making

Managed care knowledge

Education

Associate degree - Nursing

Bachelor’s degree - Nursing

Job description

BlueCross BlueShield of South Carolina seeks an experienced nurse reviewer to adjudicate appeals and retrospective reviews for medical necessity. This full-time remote role supports Mondays–Fridays, 8:00am–5:00pm, with a strong emphasis on accurate documentation and privacy.

The ideal candidate has RN licensure in the US, clinical and utilization review experience, and the ability to analyze complex records while communicating decisions clearly.