Remote RN Appeals Analyst: Medical Necessity Expert

Southcarolinablues; Utah; Hybrid; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) plan with company match

Health and vision coverage

Paid annual leave

Nine paid holidays

On-site cafeterias and fitness centers

Job summary

BlueCross BlueShield of South Carolina is recruiting a remote RN Appeals Analyst to support Palmetto GBA processes. The role requires RN licensure in the US, nursing experience, and strong analytical review of medical necessity and policy provisions.

You will work a Monday-Friday schedule during standard business hours. This full-time position emphasizes detailed documentation, privacy, and collaboration with care teams, with eligibility for extensive benefits and professional development

Qualifications

• Associate Degree in Nursing or graduate of accredited school of nursing required.
• Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical experience.

Responsibilities

• Documents the basis of the appeal or retrospective review accurately and timely.
• Performs thorough research of service appeals based on clinical documentation and policy requirements.
• Determines precedence of issues in applying policies to clinical information and benefits.
• Performs special projects reviewing clinical information to identify quality of care issues.

Skills

Word processing

Independent work

Managed care

Clinical experience

Criteria knowledge

Good judgment

Communication skills

Persuasion

Analytical thinking

Confidentiality

Education

Associate Degree in Nursing

Graduate of Accredited School of Nursing

Job description

BlueCross BlueShield of South Carolina is recruiting a remote RN Appeals Analyst to support Palmetto GBA processes. The role requires RN licensure in the US, nursing experience, and strong analytical review of medical necessity and policy provisions.

You will work a Monday-Friday schedule during standard business hours. This full-time position emphasizes detailed documentation, privacy, and collaboration with care teams, with eligibility for extensive benefits and professional development