RN Appeals Analyst

Palmetto GBA, LLC; Columbia (SC); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

401k retirement savings plan with公司…

Paid Time Off

Life Insurance

Education Assistance

On-site cafeterias and fitness centers

Job summary

BlueCross BlueShield of South Carolina family of companies- Palmetto GBA is seeking an experienced RN to research complex appeal and retrospective reviews for medical necessity determinations. The role emphasizes thorough clinical analysis, documentation, and adherence to regulations within a remote, full-time schedule.

You will review clinical information, apply policies, and contribute to quality assurance initiatives while maintaining patient confidentiality and high standards of care.

Qualifications

• Must have an active, unrestricted RN license in the United States and state of hire, or a valid compact multistate license.
• 2 years clinical experience plus 2 years utilization/medical review or 4 years combined clinical/utilization/quality assurance/home health.
• Strong knowledge of managed care, health care delivery systems, and clinical documentation.
• Excellent written and verbal communication; ability to handle confidential information.

Responsibilities

• Documents the basis of the appeal or retrospective review accurately and timely.
• Performs thorough research of service appeals using clinical documentation and policies.
• Determines precedence of issues applying policies to clinical data and benefits.
• Handles special projects identifying quality-of-care issues.

Skills

Word processing

Independent work

Prioritization

Managed care

Clinical experience

Medical review

Communication

Confidentiality

Analytical thinking

Decision making

Education

Associate's degree

Graduate of Accredited School of Nursing

Bachelor's degree in Nursing

Nursing degree equivalency

Tools

Microsoft Office

Job description

Summary

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose

Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.

Logistics

Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.

Location

This is a full-time, remote (40-hours/week) working an 8hr shift Monday-Friday within the hours of 8:00am-5:00pm.

Sponsorship

This position is not eligible for sponsorship now or in the future.

What You'll Do

• 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.

Required Education

• Associate's in a job related field
• Degree Equivalency: Graduate of Accredited School of Nursing

Required Work Experience

• 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling 4 years.

Required Skills and Abilities

• 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.

Required Software and Tools

• Microsoft Office.

Required License and Certificate

• An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

Preferred Education

• Bachelor's degree- Nursing.

Preferred Work Experience

• 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.

Preferred Skills and Abilities

• Administrative Law Judge (ALJ) process.
• Knowledge of statistical principles.
• Knowledge of National Committee for Quality Assurance (NCAG).
• Knowledge of Utilization Review Accreditation Commission (URAC).
• Knowledge of South Carolina Department of Insurance (SCDOI).
• Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations.
• Excellent organizational and time management skills.
• Knowledge of claims systems.
• Presentation skills.

Preferred Software and Other Tools

• Excel or other spreadsheet software.
• Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.

Work Environment

• Remote. Deadline driven environment.

Benefits

• Subsidized health plans, dental and vision coverage.
• 401k retirement savings plan with company match.
• Life Insurance.
• Paid Time Off (PTO).
• On-site cafeterias and fitness centers in major locations.
• Education Assistance.
• Service Recognition.
• National discounts to movies, theaters, zoos, theme parks and more.

What We Can Do for You

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email or call with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.