Appeals Analyst Medicare Part B – CGS

Summary

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.

Logistics – one of Blue Cross Blue Shield’s South Carolina subsidiary companies. This position is full time (40 hours/week) Monday-Friday 8:00-4:30 PM CST and will be W@H OR On-site at One Century Plaza, Nashville, TN.

• 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.

• Associate’s degree in a job‑related field.
• Graduate of an Accredited School of Nursing.
• 2 years of clinical experience plus 1 year of utilization/medical review, quality assurance, or home health, OR 3 years of clinical experience.
• For PALMETTO GBA (CO. 033) only: 2 years of clinical experience plus 2 years of utilization/medical review, quality assurance, or home health experience, or a combination 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 proficiency.
• Required license & certificate:
  An active, unrestricted RN license from the United States and in the state of hire, or an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

• Utilization Review / Medical Review experience.
• MCS System knowledge.
• Medicare Part B knowledge.
• CMS knowledge.
• Knowledge of claims systems.
• Ability to effectively use Microsoft Office applications such as Word, PowerPoint, and Excel.
• Coding experience.

• 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.

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.

Blue Cross Blue Shield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment…