RN Appeals Analyst

BlueCross BlueShield of South Carolina; South Carolina; Remote; USD 71,000 - 98,000; Full time

Job summary

Join a leading insurance company as an RN Appeals Analyst. In this role, you will analyze complex appeal requests and ensure compliance with medical necessity guidelines. This full-time position offers remote work flexibility after training, with a focus on quality assurance in healthcare.

Benefits

Subsidized health plans

401k retirement savings plan with company match

Paid Time Off (PTO)

Education Assistance

Qualifications

• 2 years clinical experience plus 1 year utilization/medical review.
• Active RN license required.

Responsibilities

• Research and analyze complex appeal requests.
• Document decisions within mandated timeframes.
• Perform thorough research based on clinical documentation.

Skills

Analytical Skills

Communication

Customer Service

Judgment Skills

Education

Associate's in a job related field

Graduate of Accredited School of Nursing

Tools

Microsoft Office

Job description

Join to apply for the RN Appeals Analyst role at BlueCross BlueShield of South Carolina

1 day ago Be among the first 25 applicants

Join to apply for the RN Appeals Analyst role at BlueCross BlueShield of South Carolina

Summary

We are currently hiring for an RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as an RN Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Document decisions within mandated timeframes and in compliance with applicable regulations or standards.

Summary

We are currently hiring for an RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as an RN Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Document decisions within mandated timeframes and in compliance with applicable regulations or standards.

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 have been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description

Logistics

This position is full-time (40 hours/week) Monday – Friday with the flexibility to work anytime during the hours between 7:30am to 5:00pm. The location for this position will be fully remote - upon completion of onsite training within 2 hours of a BlueCross BlueShield of SC office in South Carolina and can be remote if located within 2 hours driving distance to South Carolina as there will be the occasional need for in house visits to the office in South Carolina.

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 the Following:

• Required Education: Associate's in a job related field.
• Degree Equivalency: Graduate of Accredited School of Nursing.
• Required Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 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 four 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 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).
• Required Software and tools: Microsoft Office.
• Work Environment: Typical office environment. Deadline driven environment.
  
  

We Prefer That You Have The Following

• Emergency room ICU experience or broad clinical experience.
• Utilization Management experience.
• Case Management experience.
• Billing or Claims review experience.
  
  

Our Comprehensive Benefits Package Includes The Following

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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.

What To Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.

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.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Insurance

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