RN Appeals Analyst

Palmetto GBA, LLC; Washington (District of Columbia); Remote; USD 53,000 - 102,000; Full time

Benefits offered by this job

401(k) retirement plan

Subsidized health plans

Life insurance

Paid annual leave

Nine paid holidays

On-site cafeterias and fitness centers

Wellness programs

Tuition assistance

Service recognition

Incentive plan

Merit plan

Education funds

Job summary

BlueCross BlueShield of South Carolina is seeking an RN with clinical expertise to research the substance of complex appeal or retrospective review requests, ensuring medical necessity guidelines are met and documented within required timeframes.

The role is full-time and remote (40 hours/week), with CMS residency requirements in the US. You will perform detailed reviews, apply policy provisions, and support quality of care initiatives while maintaining confidentiality.

Qualifications

• Required: Associate Degree - Nursing or graduate of an Accredited School of Nursing.
• Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
• Knowledge of managed care and health care delivery systems is important.

Responsibilities

• Documents the basis of the appeal or retrospective review in an accurate and timely manner.
• Performs thorough research of the substance of service appeals based on clinical documentation, contractual requirements, governing agencies, policies and procedures.
• 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 benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

Skills

Word processing

Independence

Managed care

Clinical experience

Policy/application of criteria

Judgment

Customer service

Oral & written communication

Persuasion & influence

Analytical thinking

Education

Associate Degree - Nursing

Bachelor’s degree - Nursing

Job 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) Requirement s: 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:

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 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 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.