RN Appeals Analyst

BlueCross BlueShield of South Carolina

2d•Remote

About The Position

Summary 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. Description Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies. This position is remote, full time (40 hours/week) Monday-Friday regular office hours between 7am-5pm 40 hours/week Technology Requirements: High-speed broadband internet (fiber, DSL, or cable; satellite not supported) and a private, lockable home office. What You Will Do: 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

Requirements

Required Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing
Required work experience: Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical
Required Skills and abilities: 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
Required License and Certificate: 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

Preferred Education: Bachelor's degree- Nursing.
Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical. Medicare Part B, D and CPT coding knowledge
Preferred Skills and Abilities: Administrative Law Judge (ALJ) process. Knowledge of statistical principles. Knowledge of National Committee for Quality Assurance (NCQA). 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.
Preferred Software and Other Tools: 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

Benefits

401(k) retirement savings plan with company match
Subsidized health plans and free vision coverage
Life insurance
Paid annual leave – the longer you work here, the more you earn
Nine paid holidays
On-site cafeterias and fitness centers in major locations
Wellness programs and healthy lifestyle premium discount
Tuition assistance
Service recognition
Incentive Plan
Merit Plan
Continuing education funds for additional certifications and certification renewal