Remote RN Appeals Analyst – Medical Review Expert

033 Palmetto GBA

South Carolina

Hybrid

USD 53,000 - 102,000

Full time

4 days ago

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Benefits offered by this job

401(k) retirement savings plan with 3%

Subsidized health plans and freevision

Life insurance

Paid annual leave

Nine paid holidays

On-site cafeterias and fitness centers

Wellness programs

Tuition assistance

Service recognition

Continuing education funds

Job summary

BlueCross BlueShield of South Carolina is seeking a qualified Nurse Reviewer for Palmetto GBA, operating remotely in a full-time capacity. You will analyze complex appeals and retrospective reviews to determine medical necessity and diligently document decisions.

Required are an RN license in the United States, an associate degree or nursing graduation, and at least two years of clinical experience plus one year in utilization/medical review (or three years clinical).

Qualifications

Associate degree - Nursing or Graduate of Accredited School of Nursing.
Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
Active RN license in the United States (or compact multi-state license) required.

Responsibilities

Documents the basis of the appeal or retrospective review accurately and timely.
Performs thorough research of service appeals based on clinical documentation, policies, and regulations.
Assesses precedence of issues in applying policies to clinical information or benefit provisions.
Participates in special projects including reviews of clinical information to identify quality of care issues.