RN Appeals & Quality Compliance Leader (Hybrid)

Blue Cross Blue Shield; Columbia (SC); Hybrid; USD 90,000 - 120,000; Full time

Benefits offered by this job

Health insurance

401k retirement plan with companyMatch

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Job summary

BlueCross BlueShield of South Carolina is hiring a Corporate Appeals Manager to oversee appeals and case review operations, ensuring quality, timeliness, and regulatory compliance. You will lead a team, drive process improvements, and report results to internal and external stakeholders.

The role is full-time and hybrid in Columbia, SC, with on-site work up to 3 days/week during a 3-month training period. A RN or related licensure is required, along with strong leadership and analytical skills.

Qualifications

• Bachelor's in a job-related field required.
• RN licensure (active, unrestricted) or equivalent social work/counselor licensure per role.
• 2+ years supervisory experience or military equivalent.

Responsibilities

• Oversees appeals and case review staff and operations with focus on timely documentation and quality.
• Ensures compliance with regulatory, contract, and accreditation requirements (NCQA, HEDIS, URAC, HIPAA).
• Develops quality initiatives, oversight, and reporting for quality improvement.
• Implements tracking, trending, and cost containment initiatives; provides staff training.

Skills

Utilization review guidelines

Independent decision making

Analytical thinking

Communication skills

Leadership

Attention to detail

Education

Bachelor's in a job-related field

Nursing degree (RN) - equivalency allowed

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is hiring a Corporate Appeals Manager to oversee appeals and case review operations, ensuring quality, timeliness, and regulatory compliance. You will lead a team, drive process improvements, and report results to internal and external stakeholders.

The role is full-time and hybrid in Columbia, SC, with on-site work up to 3 days/week during a 3-month training period. A RN or related licensure is required, along with strong leadership and analytical skills.