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. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.

Description
 

Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

This position is remote, full time (40 hours/week) Monday-Friday regular office hours between 7am-5pm 40 hours/week

Technology Requirements: High-speed broadband internet (fiber, DSL, or cable; satellite not supported) and a private, lockable home office.

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:

• Required Education: 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

• Required Skills and abilities:

  • 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

• 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)

Preferred Education:

Bachelor's degree- Nursing.

Preferred Work Experience:

3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.

Medicare Part B and CPT coding knowledge

Preferred Skills and Abilities:

Administrative Law Judge (ALJ) process.

Knowledge of statistical principles.

Knowledge of National Committee for Quality Assurance (NCQA).

Knowledge of Utilization Review Accreditation Commission (URAC).

Knowledge of South Carolina Department of Insurance (SCDOI).

Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations. Excellent organizational and time management skills. Knowledge of claims systems.

Presentation skills.

Preferred Software and Other Tools:

Excel or other spreadsheet software.

Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.

Work Environment:

Typical office environment. Deadline driven environment.

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

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.

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