RN Appeals Analyst Medicare Part B - CGS

Internal Reference Number: R1051174 Summary We are currently hiring for an Appeals Analyst at BlueCross BlueShield of South Carolina. In this role you will research the substance of complex appeal or retrospective review requests including pre‑pay and post‑payment review appeal requests, conduct thorough clinical review or benefit analysis to determine if requested services meet medical necessity guidelines, and document decisions within mandated timeframes and in compliance with applicable regulations or standards. Logistics CGS, a subsidiary of BlueCross BlueShield’s South Carolina office. Full‑time (40 hours/week) Monday–Friday 8:00–4:30 PM CST; work‑from‑home or on‑site at One Century Plaza, Nashville, TN. What You Will Do Document the basis of the appeal or retrospective review accurately and on time in accordance with regulations or standards. Conduct 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. Perform 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 benefit or policy provisions. Lead special projects, including reviews of clinical information to identify quality of care issues. To Qualify for This Position, You Will Need Associate's degree in a related field. Graduate of an accredited school of nursing. Two years of clinical experience plus one year of utilization/medical review, quality assurance, or home health, OR three years of clinical experience. (For PALMETTO GBA, CO. 033 only: two years clinical plus two years utilization/medical review, quality assurance, or home health or a combination totaling four years.) Proficiency with word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and health care delivery systems. Strong clinical experience including home health, rehabilitation, and/or broad medical‑surgical experience. Knowledge of specific criteria/protocol sets and their use. Good judgment and analytical or critical thinking skills. Demonstrated customer service, organizational, oral and written communication skills. Ability to persuade, negotiate, or influence others. Ability to handle confidential or sensitive information with discretion. Microsoft Office proficiency. Required license: an active, unrestricted RN license from the United States and in the state of hire, or an active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact. Preferred Qualifications Utilization Review / Medical Review experience. Knowledge of MCS systems. Medicare Part B experience. CMS knowledge. Experience with claims systems. Proficiency with Microsoft Office applications such as Word, PowerPoint, and Excel. Coding experience. Benefits 401(k) retirement savings plan with company match. Subsidized health plans and free vision coverage. Life insurance. Paid annual leave that increases with tenure. Nine paid holidays. On‑site cafeterias and fitness centers at major locations. Wellness programs and healthy‑lifestyle premium discounts. Tuition assistance. Service recognition. Incentive plan. Merit plan. Continuing education funds for additional certifications and renewal. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and its subsidiaries maintain a continuing policy of nondiscrimination in employment to promote opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information, and any other legally protected status. As a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. The company provides equal opportunities in all phases of the employment process and complies with applicable federal, state, and local laws and regulations. Accommodations We are committed to providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy‑related conditions, and individuals needing accommodation for sincerely held religious beliefs, provided those accommodations do not impose an undue hardship on the company. If you need special assistance while seeking employment, please email View email address on click.appcast.io or call View phone number on click.appcast.io with the nature of your request. We will determine the request on a case‑by‑case basis. Compliance We participate in E‑Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. #J-18808-Ljbffr BlueCross BlueShield of South Carolina