RN Appeals Analyst

Other companies come and go, but we've been part of the national landscape for more than seven decades, 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated time frames and in compliance with applicable regulations or standards.

Palmetto GBA- one of Blue Cross Blue Shield of South Carolina's subsidiary companies.

This is a full-time, remote (40-hours/week) working an 8hr shift Monday-Friday within the hours of 8:00am-5:00pm. Centers for Medicare and Medicaid Services (CMS) Requirement s:
Certain divisions within Blue Cross Blue Shield of South Carolina require CMS (Centers for Medicare and Medicaid Services) residency that requires employees to have lived in the US for at least three (3) out of the last five (5) years. This is a business requirement - government contracts, not an HR requirement.

• 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

• Required
  
  Education:
  
  Associate Degree - Nursing or Graduate of Accredited School of Nursing
• Required work experience:
  Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical
• 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

• 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)

• Three years-utilization/medical review, quality assurance, or home health, plus five years clinical
• Bachelor's degree
  - Nursing
• 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

• 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…