RN Appeals Analyst: Clinical Review & Med Necessity

Palmetto GBA, LLC; Iowa City (IA); À distance; USD 53 000 - 102 000; Plein temps

Résumé du poste

BlueCross BlueShield of South Carolina is seeking a Registered Nurse to perform clinical review and medical necessity determinations for complex appeals and retrospective reviews. This is a full-time remote role with standard 8:00am–5:00pm hours and CMS residency requirements; candidates must hold an active RN license in the U.S.

and have 2 years of clinical experience plus 1 year of utilization/medical review or 3 years clinical experience.

Qualifications

• Active, unrestricted RN license in the United States
• Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR three years clinical
• Familiarity with managed care and health care delivery systems

Responsabilités

• 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

Connaissances

RN license US

Documentation skills

Analytical thinking

Independent work

Time management

Communication skills

Formation

Associate Degree - Nursing

Bachelor's degree - Nursing

Description du poste

BlueCross BlueShield of South Carolina is seeking a Registered Nurse to perform clinical review and medical necessity determinations for complex appeals and retrospective reviews. This is a full-time remote role with standard 8:00am–5:00pm hours and CMS residency requirements; candidates must hold an active RN license in the U.S.

and have 2 years of clinical experience plus 1 year of utilization/medical review or 3 years clinical experience.