Remote RN Appeals Analyst: Medical Necessity Expert

Palmetto GBA, LLC; Washington (District of Columbia); Remote; USD 53.000 - 102.000; Vollzeit

Benefits dieser Stelle

401(k) retirement plan

Subsidized health plans

Life insurance

Paid annual leave

Nine paid holidays

On-site cafeterias and fitness centers

Wellness programs

Tuition assistance

Service recognition

Incentive plan

Merit plan

Education funds

Zusammenfassung

BlueCross BlueShield of South Carolina is seeking an RN with clinical expertise to research the substance of complex appeal or retrospective review requests, ensuring medical necessity guidelines are met and documented within required timeframes.

The role is full-time and remote (40 hours/week), with CMS residency requirements in the US. You will perform detailed reviews, apply policy provisions, and support quality of care initiatives while maintaining confidentiality.

Qualifikationen

• Required: Associate Degree - Nursing or graduate of an Accredited School of Nursing.
• Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
• Knowledge of managed care and health care delivery systems is important.

Aufgaben

• Documents the basis of the appeal or retrospective review in an accurate and timely manner.
• Performs thorough research of the substance of service appeals based on clinical documentation, contractual requirements, governing agencies, policies and procedures.
• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and/or benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Kenntnisse

Word processing

Independence

Managed care

Clinical experience

Policy/application of criteria

Judgment

Customer service

Oral & written communication

Persuasion & influence

Analytical thinking

Ausbildung

Associate Degree - Nursing

Bachelor’s degree - Nursing

Jobbeschreibung

BlueCross BlueShield of South Carolina is seeking an RN with clinical expertise to research the substance of complex appeal or retrospective review requests, ensuring medical necessity guidelines are met and documented within required timeframes.

The role is full-time and remote (40 hours/week), with CMS residency requirements in the US. You will perform detailed reviews, apply policy provisions, and support quality of care initiatives while maintaining confidentiality.