RN Appeals Analyst

BlueCross BlueShield of South Carolina

1d•Hybrid

About The Position

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’ve 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 dedicated 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 Logistics This position is full time (40 hours/week) Monday-Friday, 8:30 am – 5:00 pm and will be located at 4101 Percival Road, Columbia S.C., 29219. This role is eligible to work remotely after training (3-4 weeks). Must be able to travel to the Columbia, SC office occasionally throughout the year.

Requirements

Associate Degree - Nursing or Graduate of Accredited School of Nursing.
Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, three years clinical.
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, including home health, rehabilitation, and broad medical surgical experience.
Knowledge of specific criteria/protocol sets and the use of the same.
Good judgment skills.
Demonstrate 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).

Nice To Haves

Bachelor's Degree - Nursing.
Three years-utilization/medical review, quality assurance, or home health, plus five years clinical.
Two years of BCBSSC UM, CM, Appeals, and/or Claims experience.
Knowledge of the National Committee for Quality Assurance (NCQA).
Knowledge of Utilization Review Accreditation Commission (URAC).
Knowledge of the 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.

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 the ability to define and determine the precedence of pertinent issues in applying policies and procedures to clinical information and or application to benefit or policy provisions.
Performs special projects, including reviews of clinical information to identify the quality-of-care issues.

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