RN Appeals Analyst

About the role

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 timeframes and in compliance with applicable regulations or standards. Logistics: CGS -one of BlueCross BlueShield's South Carolina subsidiary companies. Location This position is full time (40 hours/week) Monday-Friday from 8:00am - 5:00pm and will be fully remote.

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.
• To Qualify for This Position, You'll Need the Following:
• Required Education: Associate's in a job-related field
• Degree Equivalency: Graduate of Accredited School of Nursing
• Required Software and Tools: Microsoft Office.
• Required License and Certificate: 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).
• We Prefer That You Have the Following:
• Preferred Education: Bachelor's degree- Nursing.
• Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.
• Preferred Skills and Abilities: Administrative Law Judge (ALJ) process.
• Knowledge of statistical principles.
• Knowledge of the 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.
• Preferred Software and Other Tools: Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.
• Our Comprehensive Benefits Package Includes the Following:
• We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
• 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
• Equal Employment Opportunity Statement

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