Remote RN Appeals Analyst: Medical Necessity Review

Palmetto GBA, LLC; Atlanta (GA); Remote; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) retirement savings plan with 2%

Subsidized health plans

Life insurance

Paid annual leave

Job summary

BlueCross BlueShield of South Carolina is seeking a qualified RN with two years of clinical experience and additional utilization/medical review exposure. The role involves researching and documenting appeals and retrospective reviews in compliance with healthcare regulations.

Requires an active RN license (US state) or multi-state compact license. This is a full-time remote position with CMS residency requirements for some divisions. Competitive benefits are offered.

Qualifications

• Required Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing.
• Required work experience: Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
• Required Skills and abilities: See list of required skills and competencies.

Responsibilities

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• 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 application to benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Skills

Word processing

Independent work

Managed care

Clinical experience

Criteria/protocol sets

Judgment

Communication

Persuasion

Analytical thinking

Confidentiality

Education

Associate Degree - Nursing or Graduate of Accredited School of Nursing

Tools

Job description

BlueCross BlueShield of South Carolina is seeking a qualified RN with two years of clinical experience and additional utilization/medical review exposure. The role involves researching and documenting appeals and retrospective reviews in compliance with healthcare regulations.

Requires an active RN license (US state) or multi-state compact license. This is a full-time remote position with CMS residency requirements for some divisions. Competitive benefits are offered.