RN Appeals Analyst
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Remote
Location: South Carolina • United States
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About the role
- Research the substance of complex appeal or retrospective review requests
- Provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines
- Document decisions within mandated timeframes and in compliance with applicable regulations or standards
- Performs thorough research of the substance of service appeals by both member and provider
- Adhere to confidentiality regulations regarding protected health information
- Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information
- Perform special projects including reviews of clinical information to identify quality of care issues
Requirements
- Associate's in a job related field
- Graduate of Accredited School of Nursing
- 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical
- FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years.
- 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
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- 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)
Benefits
- Subsidized health plans
- Dental coverage
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewbenefit analysismedical necessity guidelinesutilization reviewquality assurancehome health experienceanalytical skillscritical thinkingconfidentiality regulationscriteria/protocol sets
Soft Skills
independent workprioritizationdecision makinggood judgmentdiscretion
Certifications
RN licensecompact multistate RN license