Remote RN Appeals Analyst: Medical Review & Policy

Palmetto GBA, LLC; Lincoln (NE); Remote; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) retirement plan with company 3%

Subsidized health plans

Life insurance

Paid annual leave

Nine paid holidays

Tuition assistance

Education and certification support

Job summary

BlueCross BlueShield of South Carolina is seeking a Remote RN reviewer to analyze complex appeal requests, determine medical necessity, and document decisions within required timeframes. Role involves research of clinical data, policy interpretation, and handling confidential information.

Requires an active RN license in the United States, 2 years clinical experience plus 1 year utilization/medical review or 3 years clinical, and knowledge of managed care and HIPAA.

Qualifications

• RN license in the United States and state of hire or compact multi-state license.
• Two years clinical experience plus one year utilization/medical review or three years clinical experience.
• Knowledge of managed care, care delivery systems, and HIPAA.

Responsibilities

• Document appeals and retrospective reviews accurately and timely.
• Research service appeals based on clinical data and policies.
• Apply policies to determine precedence in clinical information and benefits.
• Perform special projects addressing quality of care issues.

Skills

RN license

Clinical experience

Utilization review

Home health experience

Strong analytical skills

Confidentiality

Decision making

Education

Associate Degree - Nursing

Job description

BlueCross BlueShield of South Carolina is seeking a Remote RN reviewer to analyze complex appeal requests, determine medical necessity, and document decisions within required timeframes. Role involves research of clinical data, policy interpretation, and handling confidential information.

Requires an active RN license in the United States, 2 years clinical experience plus 1 year utilization/medical review or 3 years clinical, and knowledge of managed care and HIPAA.