RN Appeals Analyst

BlueCross BlueShield of South Carolina

RN Appeals Analyst responsible for researching complex medical appeal requests at BlueCross BlueShield. Perform clinical reviews and benefit analyses to ensure compliance with regulations.

Posted 5/25/2026full-timeRemote • Tennessee • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal 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.
Document the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
Perform 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.
Perform 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.
Perform special projects including reviews of clinical information to identify quality of care issues.

Requirements

What you’ll need

Required Education: Associate's in a job-related field
Degree Equivalency: Graduate of Accredited School of Nursing
Required Work Experience: 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.
Required Skills and Abilities: 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.
Demonstrated customer service, organizational, oral and written communication skills.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Required Software and Tools: Microsoft Office.
Required License and Certificate: 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

Comp & perks

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

ATS Keywords

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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 makingcustomer serviceorganizational skillsoral communicationwritten communicationpersuasionnegotiationdiscretion

Certifications

active RN licensecompact multistate RN license