Remote Nurse Analyst

We are currently hiring for an RN Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as an RN Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests, 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. This position is full-time (40 hours/week) Monday-Friday from fully remote in South Carolina or Georgia. 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. Associates in a job-related field Graduate of Accredited School of Nursing Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. 033) ONLY: 2 years clinical experience plus 2 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. Working knowledge of word processing software. 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. Demonstrated customer service, organizational, oral and written communication skills. Ability to handle confidential or sensitive information with discretion. Required Software and Tools: Microsoft Office. 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). Bachelor's degree- Nursing. Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical. Administrative Law Judge (ALJ) process. Knowledge of National Committee for Quality Assurance (NCAG). Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Knowledge of claims systems. Preferred Software and Other Tools: Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel. Subsidized health plans, dental and vision coverage 401k retirement savings plan with company match Life Insurance On-site cafeterias and fitness centers in major locations 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 our recruiter to verify resume specifics and salary requirements. 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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. help@bcbssc.