Job Posting Title RN Appeals Analyst (W@H TN)

BlueCross BlueShield of South Carolina • Tennessee, IL

2d • Remote

About The Position

BlueCross BlueShield of South Carolina is hiring a full-time RN Appeals Analyst for CGS, one of its subsidiary companies. This fully remote position operates Monday-Friday from 8:00am – 5:00pm. The primary responsibility of this role is to research complex appeal or retrospective review requests, including pre-pay and post-payment reviews. The analyst will conduct thorough clinical reviews and benefit analyses to ensure requested services meet medical necessity guidelines. Decisions must be documented accurately and timely, adhering to all applicable regulations and standards. The role involves performing research on service appeals from both members and providers, based on clinical documentation, contractual requirements, and policies, while maintaining confidentiality of protected health information. The analyst will also define and determine precedence of pertinent issues in applying policies to clinical information and benefit provisions, and may undertake special projects to identify quality of care issues.

Requirements

• Associate's in a job-related field or 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.
• 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.
• 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.
• Administrative Law Judge (ALJ) process.
• Knowledge of statistical principles.
• Knowledge of the 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.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree