Ourhrconnect

Ourhrconnect

RN Appeals Analyst

Nashville, Tennessee · Contract

Sponsorship not specifiedDetected 1 day ago
ComplianceExcelLogisticsCustomer SupportHIPAAResearchCommunicationCritical ThinkingTime ManagementMicrosoft Office

About the role

  • Summary Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests.
  • Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines.
  • Description Logistics: CGS -one of BlueCross BlueShield's South Carolina subsidiary companies.

Responsibilities

  • Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
  • Performs special projects including reviews of clinical information to identify quality of care issues.

Requirements

  • We Prefer That You Have the Following:
  • Degree Equivalency: Graduate of Accredited School of Nursing
  • Required Software and Tools: 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).
  • Required Skills and Abilities: Working knowledge of word processing software.

Nice to have

  • Bachelor's degree- Nursing.
  • Preferred Skills and Abilities: Administrative Law Judge (ALJ) process.
  • Preferred Software and Other Tools: Excel or other spreadsheet software.
  • Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.

Skills

  • 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.
  • 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.
  • Knowledge of statistical principles.
  • Knowledge of the National Committee for Quality Assurance (NCAG).
  • Knowledge of Utilization Review Accreditation Commission (URAC).

Benefits

  • 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical.
  • 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.
  • Required Education: Associate's in a job-related field
  • Preferred Education: Bachelor's degree- Nursing.
  • Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations.
  • Our Comprehensive Benefits Package Includes the Following:
  • We offer our employees great benefits and rewards.
  • You will be eligible to participate in the benefits the first of the month following 28 days of employment.
  • Subsidized health plans, dental and vision coverage
  • 401k retirement savings plan with company match
  • On-site cafeterias and fitness centers in major locations

Equal opportunity

  • 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.
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