RN Appeals Analyst

BlueCross BlueShield of South Carolina

8d•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 Location This position is full-time (40 hours/week) Monday – Friday with the flexibility to work anytime during the hours between 7:30am to 5:00pm. The location for this position will be fully remote in South Carolina. Orientation & Training: If a candidate lives more than 50 miles away, they can do orientation and training remotely If they live less than 50 miles away, they must come on-site for orientation and training (as long as it's being offered on-site) Equipment Pickup: Regardless of distance, all candidates must come into the office at least one day to pick up their equipment However, for candidates over 50 miles away, they try to limit in-office time to just the equipment pickup day 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

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

3 years- claims/utilization/medical review, quality assurance, or home health, plus 5 years clinical
Excel or other spreadsheet software.
Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel
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.

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.