Remote RN Appeals Analyst - Medical Necessity Expert

Palmetto GBA, LLC; Columbia (SC); À distance; USD 65 000 - 90 000; Plein temps

Avantages offerts par ce poste

401k retirement savings plan with公司…

Paid Time Off

Life Insurance

Education Assistance

On-site cafeterias and fitness centers

Résumé du poste

BlueCross BlueShield of South Carolina family of companies- Palmetto GBA is seeking an experienced RN to research complex appeal and retrospective reviews for medical necessity determinations. The role emphasizes thorough clinical analysis, documentation, and adherence to regulations within a remote, full-time schedule.

You will review clinical information, apply policies, and contribute to quality assurance initiatives while maintaining patient confidentiality and high standards of care.

Qualifications

• Must have an active, unrestricted RN license in the United States and state of hire, or a valid compact multistate license.
• 2 years clinical experience plus 2 years utilization/medical review or 4 years combined clinical/utilization/quality assurance/home health.
• Strong knowledge of managed care, health care delivery systems, and clinical documentation.
• Excellent written and verbal communication; ability to handle confidential information.

Responsabilités

• Documents the basis of the appeal or retrospective review accurately and timely.
• Performs thorough research of service appeals using clinical documentation and policies.
• Determines precedence of issues applying policies to clinical data and benefits.
• Handles special projects identifying quality-of-care issues.

Connaissances

Word processing

Independent work

Prioritization

Managed care

Clinical experience

Medical review

Communication

Confidentiality

Analytical thinking

Decision making

Formation

Associate's degree

Graduate of Accredited School of Nursing

Bachelor's degree in Nursing

Nursing degree equivalency

Outils

Microsoft Office

Description du poste

BlueCross BlueShield of South Carolina family of companies- Palmetto GBA is seeking an experienced RN to research complex appeal and retrospective reviews for medical necessity determinations. The role emphasizes thorough clinical analysis, documentation, and adherence to regulations within a remote, full-time schedule.

You will review clinical information, apply policies, and contribute to quality assurance initiatives while maintaining patient confidentiality and high standards of care.