Summary
 

We are currently hiring for a RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as the RN Appeals Analyst, you will research the substance of complex appeal or retrospective review requests, including pre-pay and post-payment review appeal requests. You will also provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines, and document decisions within mandated timeframes and in compliance with applicable regulations or standards.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we have been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Location:

A regular work schedule will be set between the hours of 6:30am - 6:00pm Monday through Friday with the flexibility to work 8 hours per day, five days a week or 10 hours per day, four days a week. Two weeks onsite training is required for this role. Training will be held at 17 Technology Circle, Columbia, SC. Following training, the position will be 100% work from home.

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

To Qualify for This Position, You Will Need:

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)

Required Education:

• Associates Degree - Nursing or Graduate of Accredited School of Nursing

Required Work Experience:

• Two years clinical experience plus two 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

Required Skills and Abilities:

• 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 bro