RN Corporate Appeals Manager

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

SummaryWe 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.DescriptionLocation: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 fieldDegree Equivalency: 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: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 coverage401k retirement savings plan with company matchLife InsurancePaid Time Off (PTO)On-site cafeterias and fitness centers in major locationsEducation AssistanceService RecognitionNational discounts to movies, theaters, zoos, theme parks and moreWhat 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.Equal Employment Opportunity StatementBlueCross 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 .