RN Corporate Appeals Manager

001 BlueCross and BlueShield of South Carolina; Columbia (SC); Hybrid; USD 90,000 - 130,000; Full time

Benefits offered by this job

Subsidized health plans

Dental and vision coverage

401k retirement savings plan

Life Insurance

Paid Time Off

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 services, ensuring timely documentation and quality. The role leads staff and collaborates with internal and external customers, with a focus on compliance and program results.

The position is full-time, hybrid in Columbia, SC, with on-site reporting during a 3‑month training period and a 40-hour week schedule. RN licensure or related qualifications are required.

Qualifications

• Bachelor's in a job-related field.
• Graduate of Accredited School of Nursing; equivalency not applicable for certain groups.
• 5 years’ clinical experience including appeals or utilization review.

Responsibilities

• Oversee appeals/case review services and staff to meet regulatory standards.
• Develop and implement quality initiatives and compliance oversight.
• Track trends, cost containment, and provide reporting for quality improvement.
• Provide clinical input for complex case reviews and staff training.
• Recruit, hire, train, and retain staff; interface with internal/external customers.

Skills

Utilization Review

Staff Supervision

Regulatory Knowledge

Microsoft Office

Analytical Thinking

Prioritization

Communication Skills

Process Improvement

Education

Bachelor's in a job-related field

Graduate of Accredited School of Nursing

Tools

Microsoft Office

Job description

Summary

We are currently hiring for a Corporate Appeals Manager to join BlueCross BlueShield of South Carolina. In this role as a Corporate Appeals Manager, you will oversee appeals process/case review process and staff ensuring all documentation, timeliness, and quality standards are met. Ensures cost effective plans provide a positive impact on the quality of life and clinical outcomes of individuals. Ensures compliance with state and federal requirements. Identifies and implements process improvement opportunities. Presents programs and program results to internal/external customers.

Description

Location: This position is full-time (40 hours/week) Monday‑Friday, from 8:30am – 5:00pm EST and will be hybrid in Columbia, SC. The candidate will be required to report on‑site up to 3‑days a week during the 3‑month training period.

What You’ll Do

Oversees appeals/case review clinical and support staff and operations and identifies training needs of staff. Supervises the development and administration of appeals/case review services ensuring regulatory, contract, national accreditation and program requirements are met (including NCQA, HEDIS, URAC, DOL, DOI, and HIPAA). Identifies, develops, and implements quality initiatives, compliance oversight, corrective actions, and provides reporting as required for quality improvement. Develops and implements tracking, trending, and cost containment initiatives. Provides clinical input/direction for advanced and complicated case review. Interfaces with internal and external customers. Develops and presents appeals/case review educational programs. Provides oversight of employee recruitment, hiring, training, and retention strategies.

To Qualify for This Position, You'll Need the Following

Required Education

• Bachelor's in a job‑related field
• Graduate of Accredited School of Nursing. (Equivalency not applicable for the Celerian Group. Bachelor's degree required.)

Required Experience

• 5 years’ clinical experience to include direct patient care, appeals, or utilization review.
• 2 years supervisory/team lead experience (concurrent) or equivalent military experience in grade E4 or above.

Required Skills and Abilities

• Knowledge/understanding of utilization review guidelines, managed care delivery systems.
• Working knowledge of word processing, spreadsheet, presentation software.
• Ability to work independently, prioritize effectively, make sound decisions.
• Effective customer service and organizational skills.
• Demonstrated presentation skills in order to work effectively with both internal and external customers.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical or critical thinking skills.
• Ability to persuade, negotiate, or influence others.
• Ability to handle confidential or sensitive information with discretion.
• Ability to direct, motivate, and assess performance of others.

Required Software and Tools

• Microsoft Office.

Required License/Certificate

• Active, unrestricted RN licensure 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), OR, active, unrestricted licensure as Social Worker or Counselor from the United States and in the state of hire (for Div.75 only).

What We Prefer You to Have

• Strong Leadership Skills: Ability to lead and motivate a team, fostering a positive and productive work environment.
• Excellent Communication: Clear and effective communication skills, both written and verbal, to interact with stakeholders at all levels.
• Analytical Thinking: Strong analytical skills to assess complex cases and make informed decisions.
• Attention to Detail: Meticulous attention to detail to ensure accuracy and compliance in all aspects of the appeals process.
• Problem‑Solving Abilities: Creative and proactive approach to identifying and resolving issues.
• Driven: A strong inner motivation to achieve goals, overcome challenges, and continuously improve.

Our Comprehensive Benefits Package Includes the Following

• 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.

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.

We are a Strong Supporter of Veterans

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.

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. If you are dedicated to the same philosophy, consider joining our team!