Remote RN Appeals Analyst — Medical Review Expert
Palmetto GBA, LLC
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Benefits offered by this job
Job summary
BlueCross BlueShield of South Carolina is seeking an experienced reviewer to analyze complex appeal requests and determine medical necessity. You will document decisions within required timeframes and ensure compliance with regulations while handling protected health information with discretion.
The role requires an active RN license, 2+ years of clinical or 1 year in utilization/medical review, and strong analytical and communication skills to support policy application and quality assurance
Qualifications
- Associate degree nursing required; RN license in the state of hire or active compact license.
- Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical.
- Familiarity with managed care and health care delivery systems.
Responsibilities
- Document appeal or retrospective review bases accurately in a timely manner.
- Research service appeals using clinical docs, contracts, policies, and governing rules.
- Apply policies to clinical data and benefit provisions; support special reviews.
Skills
Education
Job description
BlueCross BlueShield of South Carolina is seeking an experienced reviewer to analyze complex appeal requests and determine medical necessity. You will document decisions within required timeframes and ensure compliance with regulations while handling protected health information with discretion.
The role requires an active RN license, 2+ years of clinical or 1 year in utilization/medical review, and strong analytical and communication skills to support policy application and quality assurance
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