Analyst, Appeals

BlueCross BlueShield of South Carolina

. Research complex appeal and retrospective review requests, including pre-pay and post-payment appeals .

Posted 9/24/2026full-timeRemote • South Carolina • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates strong clinical expertise in medical necessity guidelines and appeals processing, with proficiency in documentation and compliance. Capable of conducting thorough clinical reviews and utilizing analytical skills to assess quality-of-care issues.

Highest-signal resume keywords

Active RN LicenseClinical ExperienceMedical Claims ProcessingUtilization ReviewMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewBenefit AnalysisMedical Necessity GuidelinesQuality AssuranceHome Health ExperienceIntermediate Excel SkillsAppeals ProcessingCoding KnowledgeDocumentation AccuracyContractual Requirements

Soft Skills

Analytical SkillsCritical ThinkingOrganizational SkillsOral CommunicationWritten Communication

Tools & Technologies

Word Processing SoftwareMicrosoft OfficeDual Screen Navigation

Certifications & Qualifications

Active RN LicenseCompact Multistate RN License

Industry Keywords

Managed CareHealth Care Delivery SystemsMedicare Part BClinical DocumentationRegulatory Compliance

About the role

Key responsibilities & impact

Research complex appeal and retrospective review requests, including pre-pay and post-payment appeals
Conduct clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines
Document appeal and retrospective review decisions accurately, timely, and in compliance with applicable regulations or standards
Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures
Apply policies, procedures, clinical information, benefit provisions, and precedence to appeal and retrospective reviews
Conduct special projects, including reviewing clinical information to identify quality-of-care issues
Complete approximately 8–12 weeks of training before beginning the regular shift

Requirements

What you’ll need

Associate's in a job related field
Graduate of Accredited School of Nursing accepted as degree equivalency
2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience, or a combination totaling four years
Working knowledge of word processing software
Working knowledge of managed care and various forms of 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
Working knowledge of Microsoft Office
Active, unrestricted RN license from the United States and in the state of hire, or active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC)
Experience in medical claims processing, appeals, or coding strongly preferred
Medicare Part B experience preferred
Strong computer proficiency, including navigating multiple systems and working across dual screens efficiently
Intermediate-level Excel skills
Experience creating letters and documents by reviewing appeals and extracting information accurately
Ability to work independently, prioritize effectively, make sound decisions, persuade, negotiate, or influence others, and handle confidential or sensitive information with discretion
Demonstrated judgment, customer service, organizational, oral and written communication, analytical, and critical thinking skills

Benefits

Comp & perks

Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more