Offer summary

Qualifications:

Active, unrestricted RN license from the United States or compact multistate RN license., Associates Degree in Nursing or graduate of an accredited school of nursing., Two years of clinical experience plus two years in utilization/medical review or quality assurance., Strong clinical experience in home health, rehabilitation, or broad medical surgical settings..

Key responsabilities:

Research and document the basis of appeal or retrospective review requests accurately and timely.

Perform thorough reviews of service appeals based on clinical documentation and contractual requirements.

Conduct special projects to identify quality of care issues through clinical information reviews.

Ensure compliance with confidentiality regulations regarding protected health information.

Job description

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 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

Required Software:

Microsoft Office suite.

What We Prefer:

Two years of home health or hospice clinical nursing experience
3 years-utilization/medical review, quality assurance, hospice or home health, plus 5 years clinical

What We Can Do for You:

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.

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information .

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.