Note: The job is a remote job and is open to candidates in USA. Palmetto GBA is one of BlueCross BlueShield's South Carolina subsidiary companies. The Analyst, Appeals role involves researching complex appeal requests and providing clinical reviews to determine medical necessity, ensuring compliance with regulations.
Responsibilities
- 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
Skills
- Associate's in a job related field
- Graduate of Accredited School of Nursing
- 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 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
- 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
- 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)
- 5 years of clinical experience
- Experience in medical claims processing, appeals, or coding strongly preferred
- Medicare Part B experience preferred
- Strong computer proficiency, with the ability to navigate multiple systems and work across dual screens efficiently
- Intermediate-level Excel skills
- Experience creating letters and documents by reviewing appeals and extracting information with a high degree of accuracy; updates departmental documents as needed
Benefits
- Subsidized health plans, dental and vision coverage
- 401k 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
- National discounts to movies, theaters, zoos, theme parks and more
- You will be eligible to participate in the benefits the first of the month following 28 days of employment.
Company Overview