Remote RN Appeals Analyst - Medical Review Expert

Palmetto GBA, LLC; Sioux Falls (SD); Remote; USD 53,000 - 102,000; Full time

Job summary

BlueCross BlueShield of South Carolina seeks a registered nurse to conduct complex appeal and retrospective review analyses to determine medical necessity in line with guidelines and timeframes. You will document decisions with high attention to privacy and regulatory compliance.

This full-time remote role requires an active US RN license, 2+ years clinical experience plus 1 year in utilization/medical review (or 3 years clinical), and solid knowledge of managed care.

Qualifications

• Working knowledge of word processing software
• Ability to work independently, prioritize effectively, and make sound decisions.
• Working knowledge of managed care and various forms of health care delivery systems
• Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience
• Knowledge of specific criteria/protocol sets and the use of the same
• Good judgment skills
• Demonstrated customer service, organizational, oral and written communication skills
• Ability to persuade, negotiate, or influence others
• Analytical or critical thinking skills
• Ability to handle confidential or sensitive information with discretion

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

Independent work

Prioritize effectively

Managed care knowledge

Clinical experience

Decision making

Customer service

Communication skills

Persuasion/influence

Analytical thinking

Confidential information handling

Education

Associate Degree - Nursing

Graduate of Accredited School of Nursing

Job description

BlueCross BlueShield of South Carolina seeks a registered nurse to conduct complex appeal and retrospective review analyses to determine medical necessity in line with guidelines and timeframes. You will document decisions with high attention to privacy and regulatory compliance.

This full-time remote role requires an active US RN license, 2+ years clinical experience plus 1 year in utilization/medical review (or 3 years clinical), and solid knowledge of managed care.