OPA RN Appeals Analyst

BlueCross BlueShield of South Carolina•Columbia, SC

2d•Remote

About The Position

An OPA RN Appeals Analyst researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards. This position requires CMS Security Clearance as it falls within a division subject to Centers for Medicare and Medicaid Services residency requirements. BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O'Hara Service Contract Act (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date. This position is full-time (40 hours/week) Monday-Friday and will be remote. This position is not eligible for sponsorship now or in the future.

Requirements

Associate degree - Nursing or Graduate of Accredited School of Nursing.
Two years’ clinical experience plus two years utilization/medical review, quality assurance, or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience 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 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.
Microsoft Office.
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).

Nice To Haves

Bachelor's degree - Nursing.
Three years-utilization/medical review, quality assurance, or outpatient experience plus five years’ clinical.
Administrative Law Judge (ALJ) process.
Knowledge of statistical principles.
Knowledge of National Committee for Quality Assurance (NCAG).
Knowledge of Utilization Review Accreditation Commission (URAC).
Knowledge of South Carolina Department of Insurance (SCDOI).
Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations.
Excellent organizational and time management skills.
Knowledge of claims systems.
Presentation skills.
Excel or other spreadsheet software.
Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.

Responsibilities

Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
Performs 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.
Performs 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.
Performs special projects including reviews of clinical information to identify quality of care issues.