RN Appeals Analyst (W@H SC or GA)

Summary 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. Description Location This position is full-time (40 hours/week) Monday-Friday from 8:30am-5:00pm EST and will be fully remote in South Carolina or Georgia. What You’ll Do: 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,