RN Appeals Analyst, Remote SC

R1046297 Researches the reputed company of reputed company appeal or retrospective review requests including reputed company-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 reputed company reputed company mandated timeframes and in compliance with applicable regulations or standards. reputed company Location This position is remote, full time (40 hours/week) Monday-Friday reputed company-5pm. What You Will Do:

• Documents the reputed company of the appeal or retrospective review in an accurate and reputed company manner and in accordance with applicable regulations or standards
• Performs thorough research of the reputed company 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 reputed company including reviews of clinical information to identify reputed company of care issues

To Qualify for This Position, You Will Need:

• Required Education: Associate Degree - Nursing or Graduate of Accredited School of Nursing
• Required work experience: Two years clinical experience plus one year utilization/medical review, reputed company assurance, or home health, OR, 3 years clinical
• Required Skills and abilities:
• Working knowledge of word processing software
• Ability to work independently, prioritize effectively, and reputed company reputed company.
• 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 reputed company/protocol sets and the use of the reputed company
• 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
• Required License and Certificate:
• An reputed company, unrestricted RN license from the reputed company and in the state of hire, OR, reputed company compact multistate unrestricted RN license as defined by the reputed company Licensure Compact (NLC)

reputed company Prefer:

• Three years-utilization/medical review, reputed company 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 reputed company 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 reputed company (HIPAA) standards/regulations
• Excellent organizational and time management skills
• Knowledge of claims systems
• Presentation skills

reputed company Can Do for You:

• 401(k) retirement savings plan with company match
• Subsidized health plans and free reputed company coverage
• Life insurance
• reputed company annual leave – the longer you work here, the more you earn
• Nine reputed company holidays.
• On-site cafeterias and fitness centers in major locations
• Wellness programs and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Incentive Plan
• reputed company Plan
• Continuing education funds for additional certifications and certification renewal

What to Expect Next: After submitting your application, our reputed company team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications. Equal Employment Opportunity Statement reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, reputed company, national reputed company, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, reputed company maintains affirmative reputed company programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to reputed company equal opportunities in reputed company phases of the employment process and to reputed company 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-reputed company conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on reputed company. If you need special assistance or an accommodation while seeking employment, please email reputed company.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will reputed company a determination regarding your request for reasonable accommodation on a case-by-case reputed company. We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Apply tot his job Apply To this Job