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

CGS Administrators, LLC • Tennessee, IL

1d • Remote

About The Position

We are currently hiring for a RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role, you will research the substance of complex appeal or retrospective review requests, including pre-pay and post-payment review appeal requests. You will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines, documenting decisions within mandated timeframes and in compliance with applicable regulations or standards. This full-time position (40 hours/week), Monday-Friday from 8:00am – 5:00pm, will be fully remote. The company, CGS Administrators, a subsidiary of BlueCross BlueShield of South Carolina, provides services under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, health care providers, and medical equipment suppliers in 33 states, supporting the needs of more than 20 million Medicare beneficiaries nationwide.

Requirements

• Associate's degree 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 experience.
• 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 proficiency.
• 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 in Nursing.
• 3 years utilization/medical review, quality assurance, or home health experience, plus 5 years clinical experience.
• Administrative Law Judge (ALJ) process knowledge.
• 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 proficiency.
• Ability to effectively use Microsoft Office applications, such as Word, PowerPoint 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