BlueCross BlueShield of South Carolina · 2 days ago
RN Appeals Analyst Medicare Part B - CGS
Nashville, TN
Full-time
Hybrid
Mid Level
3+ years expBlueCross BlueShield of South Carolina is currently hiring for an Appeals Analyst to join their team. In this role, you will research complex appeal requests and provide clinical review to determine medical necessity, while ensuring compliance with regulations.
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
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
Microsoft Office
Required License and Certificate: 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)
Preferred
Utilization Review / Medical Review experience
MCS System Knowledge
Medicare Part B
CMS Knowledge
Knowledge of claims systems
Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel
Coding experience
Benefits
401(k) retirement savings plan with company match
Subsidized health plans and free vision coverage
Life insurance
Paid annual leave – the longer you work here, the more you earn
Nine paid holidays
On-site cafeterias and fitness centers in major locations
Wellness programs and healthy lifestyle premium discount
Tuition assistance
Service recognition
Incentive Plan
Merit Plan
Continuing education funds for additional certifications and certification renewal
Company
BlueCross BlueShield of South Carolina
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.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
April Richardson
Vice President and Chief Operating Officer of Companion Benefit Alternative
Alli McGary
Talent Acquisition Partner
Recent News
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