RN Corporate Appeals Manager

BlueCross BlueShield of South Carolina•Columbia, SC

1d•Hybrid

About The Position

BlueCross BlueShield of South Carolina is hiring a Corporate Appeals Manager to oversee the appeals and case review processes, including staff, documentation, timeliness, and quality standards. The role helps ensure cost-effective plans positively affect individuals’ quality of life and clinical outcomes, maintains compliance with state and federal requirements, identifies process improvements, and presents programs and results to internal and external customers. This is a full-time, 40-hour-per-week position, Monday through Friday, from 8:30 a.m. to 5:00 p.m. EST. The position is hybrid in Columbia, South Carolina. During the three-month training period, the employee must report onsite up to three days per week.

Requirements

Bachelor’s degree in a job-related field. The stated degree equivalency is graduation from an accredited school of nursing; equivalency does not apply for the Celerian Group, where a bachelor’s degree is required.
Five years of clinical experience, including direct patient care, appeals, or utilization review.
Two years of concurrent supervisory or team-lead experience, or equivalent military experience in grade E4 or above.
Knowledge and understanding of utilization review guidelines and managed care delivery systems.
Working knowledge of word processing, spreadsheet, and presentation software.
Ability to work independently, prioritize effectively, and make sound decisions.
Effective customer service and organizational skills.
Presentation skills for working effectively with internal and external customers.
Proficiency in spelling, punctuation, and grammar.
Analytical or critical-thinking skills.
Ability to persuade, negotiate, or influence others.
Ability to handle confidential or sensitive information discreetly.
Ability to direct, motivate, and assess the performance of others.
Required software and tools: Microsoft Office.
Active, unrestricted U.S. RN licensure in the state of hire, an active compact multistate unrestricted RN license under the Nurse Licensure Compact, or— for Division 75 only—active, unrestricted U.S. licensure as a social worker or counselor in the state of hire.

Nice To Haves

Strong leadership skills and the ability to lead and motivate a team in a positive, productive work environment.
Clear and effective written and verbal communication skills for interacting with stakeholders at all levels.
Strong analytical skills for assessing complex cases and making informed decisions.
Meticulous attention to detail to ensure accuracy and compliance in the appeals process.
Creative, proactive problem-solving abilities.
Strong motivation to achieve goals, overcome challenges, and continuously improve.

Responsibilities

Oversee appeals and case review clinical and support staff and operations, and identify staff training needs.
Supervise the development and administration of appeals and case review services to meet regulatory, contract, national accreditation, and program requirements, including NCQA, HEDIS, URAC, DOL, DOI, and HIPAA.
Identify, develop, and implement quality initiatives, compliance oversight, and corrective actions, and provide required quality-improvement reporting.
Develop and implement tracking, trending, and cost-containment initiatives.
Provide clinical input and direction for advanced and complicated case reviews.
Interface with internal and external customers.
Develop and present appeals and case review educational programs.
Oversee employee recruitment, hiring, training, and retention strategies.