RN Appeals Analyst

033 Palmetto GBA; South Carolina; Hybrid; USD 53,000 - 102,000; Full time

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.

Skills

Word processing

Independent work

Managed care knowledge

Clinical nursing experience

Confidentiality

Communication skills

Persuasion / influence

Analytical thinking

Education

Associate degree - Nursing

RN license

Job description

Summary Description 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 of South Carolina’s 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.

Centers for Medicare and Medicaid Services (CMS) Requirements:

Certain divisions within BlueCross BlueShield of South Carolina require CMS (Centers for Medicare and Medicaid Services) residency that requires employees to have lived in the US for at least three (3) out of the last five (5) years. This is a business requirement – government contracts, not an HR requirement.

What You Will 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

To Qualify for This Position, You Will Need:

Required Education:

Associate degree - Nursing or Graduate of Accredited School of Nursing

Required work experience:

Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical

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 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)

What We Prefer:

• Three years-utilization/medical review, quality assurance, or home health, plus five years clinical
• Bachelor's degree- Nursing
• 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

What We Can Do for You:

• 401(k) retirement savings plan with company match
• Subsidized health plans and free vision coverage
• Life insurance
• Paid annual leave – the longer you work here, the more you earn
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations
• Wellness programs and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Incentive Plan Merit Plan
• Continuing education funds for additional certifications and certification renewal

Pay Transparency Statement:

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

Pay Range Pay Range

Pay Range Min: $53,462.00 Pay Range Mid: $77,860.00 Pay Range Max: $102,258.00

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 [e-mail] or call 800‑288‑2227, ext. 47480 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. Here's more information. Some states have required notifications. Here's more information.

Welcome Here’s Your Smart Career Move

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers.

Veterans Welcome!

BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full‑time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.