Remote RN Appeals Analyst — Medical Review Expert

Palmetto GBA, LLC; Salem (OR); Remote; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) retirement savings plan with 2x

Subsidized health plans and freevision

Life insurance

Paid annual leave

Nine paid holidays

Continuing education funds

Job summary

BlueCross BlueShield of South Carolina is seeking an experienced RN reviewer for complex appeal and retrospective review work. The role involves researching medical necessity and documenting decisions within regulatory timeframes, in a remote full-time capacity.

Requires an active RN license in the United States and at least two years clinical experience plus one year in utilization/medical review or three years clinical. Strong analytical and communication skills are essential.

Qualifications

• Associate Degree in Nursing or equivalent.
• Two years clinical experience plus one year utilization/medical review, QA, or home health, OR three years clinical.
• Ability to work independently and prioritize effectively.
• Knowledge of managed care and health care delivery systems.

Responsibilities

• Document the basis of the appeal in accordance with regulations.
• Research the substance of service appeals using clinical documentation and policies.
• Apply policies to determine precedence in clinical information and benefits.
• Perform special projects reviewing clinical information for quality of care.

Skills

RN license

Clinical review

Utilization review

Medical records research

Confidentiality

Communication

Education

Associate Degree in Nursing

Graduate of Accredited School of Nursing

Job description

BlueCross BlueShield of South Carolina is seeking an experienced RN reviewer for complex appeal and retrospective review work. The role involves researching medical necessity and documenting decisions within regulatory timeframes, in a remote full-time capacity.

Requires an active RN license in the United States and at least two years clinical experience plus one year in utilization/medical review or three years clinical. Strong analytical and communication skills are essential.