Analyst, Appeals

BlueCross BlueShield of South Carolina

Appeals Analyst reviewing medical necessity and benefit criteria for BlueCross South Carolina health insurance claims. Documenting compliant appeal decisions and retrospective reviews.

Posted 8/5/2026full-timeRemote • South Carolina • 🇺🇸 United StatesJuniorMid-LevelWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates strong clinical expertise and analytical skills to conduct thorough reviews of medical necessity and appeals, ensuring compliance with regulations. Proficient in creating accurate documentation and effectively navigating healthcare delivery systems.

Highest-signal resume keywords

Active RN LicenseClinical ExperienceUtilization ReviewMedical Claims ProcessingMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewBenefit AnalysisQuality AssuranceMedical Necessity GuidelinesDocumentation AccuracyData AnalysisHome Health ExperienceIntermediate Excel SkillsAppeals ProcessingProtocol Knowledge

Soft Skills

JudgmentCustomer ServiceOrganizational SkillsOral CommunicationWritten CommunicationNegotiation SkillsCritical Thinking

Tools & Technologies

Word Processing SoftwareMicrosoft OfficeDual Screen Navigation

Certifications & Qualifications

Active RN LicenseNurse Licensure Compact License

Industry Keywords

Managed CareHealthcare Delivery SystemsMedicare Part BClinical DocumentationRegulatory Compliance

About the role

Key responsibilities & impact

Research complex appeal and retrospective review requests, including pre-pay and post-payment reviews
Conduct thorough clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines
Document appeal and review decisions accurately, timely, and in compliance with regulations and standards
Research member and provider service appeals using clinical documentation, contractual requirements, governing agency guidance, policies, and procedures
Apply policies, procedures, clinical information, and benefit or policy provisions to determine relevant issues and precedence
Perform special projects, including clinical information reviews to identify quality-of-care issues
Create letters and documents by reviewing appeals and extracting information accurately
Update departmental documents as needed

Requirements

What you’ll need

Associate's degree in a job-related field
Graduate of an accredited school of nursing
Required experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, or 3 years clinical experience
For Palmetto GBA (Co. 033): 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience, or a combination 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 health care delivery systems
Strong clinical experience including home health, rehabilitation, and/or broad medical-surgical experience
Knowledge of specific criteria/protocol sets and their use
Judgment, 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 discreetly
Microsoft Office proficiency
Active, unrestricted RN license from the United States and the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact
Preferred: 5 years of clinical experience
Medical claims processing, appeals, or coding experience strongly preferred
Medicare Part B experience preferred
Strong computer proficiency, including navigating multiple systems and working across dual screens
Intermediate Excel skills
Ability to create accurate letters and documents from appeal reviews and update departmental documents
Ability to work an 8-hour shift within 8:00 a.m.–4:30 p.m. Eastern Time; after training, shifts may begin as early as 6:00 a.m. Eastern Time
Approximately 8–12 weeks of training

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
Reasonable accommodations for individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs
Pay difference coverage for full-time National Guard or Reserve employees called to active duty