Remote RN Appeals Analyst - Medical Necessity Review

ourhrconnect; South Carolina; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Subsidized health plans

401k retirement savings with company

Life Insurance

Paid Time Off (PTO)

Education Assistance

Service Recognition

Job summary

BlueCross BlueShield of South Carolina is seeking a remote RN reviewer for complex appeal and retrospective review processes. The role focuses on medical necessity analyses, documentation within required timeframes, and adherence to regulations.

This is a full-time remote position with standard executive responsibilities. The candidate must hold an active RN license in the United States with state of hire or a multi-state compact license.

Qualifications

• Associate’s degree in a related field or graduation from an Accredited School of Nursing.
• Active, unrestricted RN license in the United States and in the state of hire or a valid compact multistate RN license (NLC).
• Strong clinical experience across home health, rehabilitation, or broad medical-surgical settings; solid communication and analytical skills.

Responsibilities

• Document the basis of the appeal or retrospective review accurately and promptly.
• Research the substance of service appeals based on clinical docs, regulations, and policies.
• Apply policies to determine precedence and impact on benefits or coverage.
• Participate in special projects to identify quality of care issues.

Skills

Word processing

Independent work

Time management

Decision making

Customer service

Oral written communication

Analytical thinking

Education

Associate degree in related field

Nursing degree equivalency

Bachelor’s degree - Nursing

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a remote RN reviewer for complex appeal and retrospective review processes. The role focuses on medical necessity analyses, documentation within required timeframes, and adherence to regulations.

This is a full-time remote position with standard executive responsibilities. The candidate must hold an active RN license in the United States with state of hire or a multi-state compact license.