Research and analyze complex appeal or retrospective review requests to determine if services meet medical necessity guidelines. Document decisions accurately and timely in compliance with applicable regulations and standards.
Requirements summary
Requires an active RN license, an associate degree in a related field, and a combination of clinical and utilization review experience. Must possess strong analytical skills and proficiency in Microsoft Office.
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South Carolina.
In this role as Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests.
Additionally, you will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines.
Lastly, you will document decisions within mandated timeframes and in compliance with applicable regulations or standards.
This open position is within one of our subsidiary companies called CGS Administrators.
CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years.
Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.
Description Logistics CGS –one of BlueCross BlueShield's South Carolina subsidiary companies.
This position is full time (40 hours/week) Monday-Friday 8:00-4:30PM CST and will be W@H OR On-site at One Century Plaza, Nashville TN.
What You Will 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, You Will Need: 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.
Benefits
Life Insurance
Tuition Assistance
Wellness Programs
Incentive Plan
401(k) Retirement Savings Plan With Company Match
Merit Plan
Continuing Education Funds
Service Recognition
On-site Cafeterias
On-site Fitness Centers
Nine Paid Holidays
Paid Annual Leave
Free Vision Coverage
Subsidized Health Plans
Healthy Lifestyle Premium Discount
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.
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).
What We Prefer You Have: Utilization Review / Medical Review experience.
MCS System Knowledge.
Medicare Part B.
CMS Knowledge.
Knowledge of claims systems.
Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.
Coding experience.
What We Can Do for You: 401(k) retirement savings plan with company match.
Subsidized health plans and 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.
What to Expect Next: After submitting your application, our recruiting 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 BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status.
Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans.
It is our policy to provide equal opportunities in all phases of the employment process and to comply 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-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext.
47480 with the nature of your request.
We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply 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.
If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit.
Welcome CGS Administrators provides a variety of services, under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, health care providers, and medical equipment suppliers in 33 states, supporting the needs of more than 20 million Medicare beneficiaries nationwide.
We deliver outstanding service to our customers.
If you are dedicated to the same philosophy, consider joining our team!
Want to work for a growing company with an innovative eye towards the future?
