RN Appeals Analyst

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.

Full‑time, 40 hours/week, Monday–Friday 8:00am – 5:00pm, fully remote. The position is part of CGS, a subsidiary of Blue Cross Blue Shield of South Carolina.

• Document the basis of the appeal or retrospective review accurately and in a timely manner.
• Conduct thorough research on the substance of service appeals for both members and providers based on clinical documentation, contractual requirements, governing agencies, policies and procedures.
• Adhere to confidentiality regulations regarding protected health information.
• Apply policies and procedures to clinical information to determine precedence of pertinent issues in benefit or policy provisions.
• Execute special projects, such as reviewing clinical information to identify quality of care issues.

• Education:
  • Associate’s degree in a job‑related field.
  • Degree equivalency:
    Graduate of an accredited school of nursing.
• Experience:
  • 2 years clinical experience plus 1 year in utilization/medical review, quality assurance, or home health, OR 3 years clinical.
  • FOR PALMETTO GBA ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health, totaling four years.
• Skills and Abilities:
  • Working knowledge of word processing software.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • 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 those sets.
  • Good judgment, 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.
• Software and Tools: Microsoft Office.
• License and Certificate: An active, unrestricted RN license from the United States state of hire or an active compact multistate unrestricted RN license.

• Education: Bachelor’s degree in Nursing.
• Experience: 3 years utilization/medical review, quality assurance, or home health, plus 5 years clinical.
• Skills and Abilities:
  • Administrative Law Judge (ALJ) process.
  • Knowledge of statistical principles.
  • Knowledge of the National Committee for Quality Assurance (NCQA).
  • Knowledge of Utilization Review Accreditation Commission (URAC).
  • Knowledge of South Carolina Department of Insurance (SCDOI).
  • Knowledge of U.S. Department of Labor and HIPAA standards/regulations.
  • Excellent organizational and time‑management skills.
  • Knowledge of claims systems; presentation skills.
• Software and Tools: Excel or other spreadsheet software; proficiency in Word, PowerPoint, and Excel.

• Subsidized health plans, dental and vision coverage.
• 401(k) retirement savings plan with company match.
• Life insurance.
• Paid time off (PTO).
• On‑site cafeterias and fitness centers in major locations.
• Education assistance.
• Service recognition programs.
• National discounts to movies, theaters, zoos, theme parks and more.

Blue Cross Blue Shield of South Carolina and its 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, gender identity, genetic information or any other legally protected status. As a federal contractor, the company maintains affirmative action programs to enhance opportunities for individuals with disabilities and protected veterans.

The company is committed to providing reasonable accommodations for employees with disabilities, pregnant individuals, and others as required by law.