RN - Health Care - Analysts

Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We deliver outstanding service to our customers. 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.

This is a full-time,

remote

(40-hours/week) working an 8hr shift Monday-Friday within the hours of 8:00am-5:00pm. Centers for Medicare and Medicaid Services (CMS) Requirement

s: Certain divisions within BlueCross BlueShield of South Carolina require CMS (Centers for Medicare and Medicaid Services) residency that requires employees to have lived in the US for at least three (3) out of the last five (5) years. 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 Associate Degree - Nursing or Graduate of Accredited School of Nursing Required work experience: Two years clinical experience plus one year utilization/medical review, quality assurance, or home health, OR, 3 years clinical Working knowledge of word processing software 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 Demonstrated customer service, organizational, oral and written communication skills Ability to handle confidential or sensitive information with discretion 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)

Three years-utilization/medical review, quality assurance, or home health, plus five years clinical Bachelor's degree- Nursing Administrative Law Judge (ALJ) process Knowledge of National Committee for Quality Assurance (NCAG) Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations Knowledge of claims systems 401(k) retirement savings plan with company match ~ Subsidized health plans and free vision coverage ~ Life insurance ~ Nine paid holidays. ~ On-site cafeterias and fitness centers in major locations ~ 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. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity. 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. View email address on click.appcast.io.