Remote RN Appeals Specialist

Southcarolinablues; South Carolina; Remote; USD 53.000 - 102.000; Vollzeit

Benefits dieser Stelle

401(k) retirement savings plan

Health plans

Paid annual leave

Nine paid holidays

Tuition assistance

Zusammenfassung

BlueCross BlueShield of South Carolina is seeking an RN Appeals Analyst for a fully remote, 40-hour work week with a standard Monday–Friday schedule. The role focuses on complex appeal reviews, clinical validation, and medical necessity determinations within CMS and internal guidelines.

Qualifications include an active RN license, an associate degree in nursing, and 2+ years of clinical and 1+ year in utilization/medical review. Strong research, analytical, and communication skills are essential.

Qualifikationen

• RN license in the United States and in the state of hire or multi-state compact.
• Two years of clinical experience plus one year utilization/medical review, quality assurance, or home health, or three years clinical experience.
• Strong analytical, organizational, and written communication skills.

Aufgaben

• Document basis of appeal or retrospective review in a timely, compliant manner.
• Perform thorough research of service appeals based on clinical documentation and policies.
• Determine precedence of issues when applying policies to clinical information.
• Contribute to special projects addressing quality of care issues.

Kenntnisse

Nursing experience

Clinical judgment

Research skills

Independent work

Communication

Ausbildung

Associate degree - Nursing

Jobbeschreibung

BlueCross BlueShield of South Carolina is seeking an RN Appeals Analyst for a fully remote, 40-hour work week with a standard Monday–Friday schedule. The role focuses on complex appeal reviews, clinical validation, and medical necessity determinations within CMS and internal guidelines.

Qualifications include an active RN license, an associate degree in nursing, and 2+ years of clinical and 1+ year in utilization/medical review. Strong research, analytical, and communication skills are essential.