Facebook ยท 20 hours ago
RN Appeals Analyst
W@H South Carolina
Full-time
Hybrid
Mid Level
3+ years expFacebook is seeking a RN Appeals Analyst to join their team at BlueCross and BlueShield of South Carolina. The role involves researching complex appeal requests, providing clinical reviews, and documenting decisions within mandated timeframes while ensuring compliance with regulations.
Computer Software
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
Qualification
Required
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
Preferred
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
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
Company
The Facebook company is now Meta. Meta builds technologies that help people connect, find communities, and grow businesses.
10001+ employees
H1B Sponsorship
Facebook has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2022 (942)
2021 (5811)
2020 (4476)
Funding
Current Stage
Late StageLeadership Team
Arunava Chatterjee
Executive Director of Ghost Black Operations & CEO & CTO
Shubhra Gupta
CEO
Recent News
Business Live
2025-11-03
2025-11-01
Company data provided by crunchbase