RN Appeals Analyst

CGS Administrators, LLC

RN Appeals Analyst at BlueCross BlueShield managing complex appeal requests and determining medical necessity compliance. Requires clinical experience and nursing licensure in Tennessee.

Posted 4/23/2026full-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
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
Perform appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in the 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

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
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
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

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Hard Skills & Tools

clinical reviewbenefit analysismedical necessity guidelinesutilization reviewquality assurancehome healthrehabilitationmedical surgical experiencecriteria/protocol setsword processing software

Soft Skills

independent workprioritizationdecision makingcustomer serviceorganizational skillsoral communicationwritten communicationpersuasionnegotiationanalytical thinking

Certifications

RN licensecompact multistate RN license