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RN Appeals Analyst
BlueCross BlueShield of South CarolinaRN Appeals Analyst reviewing complex health insurance appeals and medical necessity for BlueCross BlueShield of South Carolina. Documenting compliant clinical and benefit decisions for South Carolina members and providers.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong clinical expertise in medical necessity guidelines and utilization review, with a focus on compliance and quality assurance. Proficient in handling confidential information and conducting thorough clinical reviews to support decision-making in healthcare settings.
Highest-signal resume keywords
Active RN LicenseClinical ExperienceUtilization ReviewQuality AssuranceMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewBenefit AnalysisMedical Necessity GuidelinesQuality-of-Care IssuesSpecific Criteria/Protocol SetsHome Health ExperienceRehabilitation ExperienceAnalytical SkillsCritical Thinking
Soft Skills
Good JudgmentCustomer ServiceOrganizational SkillsOral CommunicationWritten CommunicationPersuasionNegotiation
Tools & Technologies
Word Processing SoftwareExcelSpreadsheet Software
Certifications & Qualifications
Associate DegreeBachelor's Degree in Nursing (Preferred)Active RN License
Industry Keywords
Managed CareHealthcare Delivery SystemsALJ Process (Preferred)NCQA (Preferred)URAC (Preferred)SCDOI (Preferred)US DOL (Preferred)HIPAA Standards/Regulations
About the role
Key responsibilities & impact- Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals
- Conduct clinical reviews and benefit analyses to determine whether requested services meet medical necessity guidelines
- Document appeal and retrospective review decisions accurately, timely, and in compliance with regulations and standards
- Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures
- Apply policies, procedures, clinical information, and benefit or policy provisions to determine pertinent issue precedence
- Perform special projects, including clinical information reviews to identify quality-of-care issues
- Handle protected health information and confidential or sensitive information in accordance with applicable requirements
Requirements
What you’ll need- Associate degree in a job-related field required
- Graduate of an accredited school of nursing required
- 2 years of clinical experience plus 1 year of utilization/medical review, quality assurance, or home health experience, or 3 years of clinical experience
- For Palmetto GBA only: 2 years of clinical experience plus 2 years of utilization/medical review, quality assurance, or home health experience, or four years combined qualifying experience
- Working knowledge of word processing software
- Ability to work independently, prioritize effectively, and make sound decisions
- Working knowledge of managed care and health care delivery systems
- Strong clinical experience including home health, rehabilitation, and/or broad medical-surgical experience
- Knowledge and use of specific criteria/protocol sets
- Good 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 with discretion
- 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: bachelor's degree in nursing
- Preferred: 3 years of utilization/medical review, quality assurance, or home health plus 5 years of clinical experience
- Preferred knowledge of ALJ process, statistical principles, NCQA, URAC, SCDOI, US DOL, HIPAA standards/regulations, claims systems, and presentation skills
- Preferred proficiency with Excel or other spreadsheet software and Microsoft Office applications
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 disabilities, pregnancy-related conditions, and sincerely held religious beliefs
- Pay differential coverage for full-time National Guard or Reserves employees called to active duty