RN Appeals Analyst

BlueCross BlueShield of South Carolina•Columbia, SC

9d•Remote

About The Position

Summary We are currently hiring for an RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as an RN Appeals Analyst, you will 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. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we have been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining our team! Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Description Location This is a full-time position (40 hours/week), Monday through Friday, with flexible hours between 7:30 AM and 5:00 PM. The role is fully remote following completion of onsite training at our Columbia, SC office (4101 Percival Road, Columbia, SC 29229). Candidates must be located within two hours of a BlueCross BlueShield of South Carolina office to accommodate occasional in-office visits as needed.

Requirements

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.
FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience 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.
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).
Microsoft Office.

Nice To Haves

Emergency room
ICU experience or broad clinical experience.
Utilization Management experience.
Case Management experience.
Billing or Claims review experience.

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.