Note: The job is a remote job and is open to candidates in USA. Palmetto GBA, a subsidiary of BlueCross BlueShield of South Carolina, is hiring an RN Appeals Analyst to research complex appeals and retrospective reviews. The role conducts clinical reviews and benefit analyses to assess medical necessity, documents decisions within required timeframes, and supports quality-of-care reviews.
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 Degree - Nursing or Graduate of Accredited School of Nursing
- Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical
- 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
Benefits
- 401(k) retirement savings plan with company match
- Subsidized health plans
- 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
- Full-time remote work (40-hours/week), working an 8hr shift Monday-Friday within the hours of 8:00am-5:00pm
Company Overview