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BlueCross BlueShield of South Carolina · 12 hours ago

RN Appeals Analyst

South Carolina, United States

Full-time

Hybrid

Mid Level

3+ years exp

BlueCross BlueShield of South Carolina is seeking an RN Appeals Analyst to research complex appeal requests and provide clinical reviews to determine medical necessity. The role involves documenting decisions in compliance with regulations and conducting thorough analyses of clinical information related to appeals.

Financial ServicesHealth CareHealth InsuranceInsuranceMedical

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

RN licenseClinical experienceUtilization reviewMicrosoft OfficeManaged care knowledgeAnalytical skillsCustomer serviceOral communicationWritten communicationOrganizational skillsTime management

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

Typical office environment

Deadline driven environment

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

BlueCross BlueShield of South Carolina

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For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state.

Founded in 1946

Columbia, South Carolina, USA

10001+ employees