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Analyst, Appeals
BlueCross BlueShield of South Carolina. Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong clinical expertise and analytical skills in performing medical necessity reviews and appeals, while ensuring compliance with confidentiality regulations and organizational standards. Proficient in utilizing various healthcare delivery systems and managing sensitive information effectively.
Highest-signal resume keywords
Active RN LicenseClinical ExperienceMedical Review ExpertiseAnalytical SkillsMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewMedical Necessity GuidelinesUtilization ReviewQuality AssuranceMedical Claims ProcessingAppeals ManagementExcel SkillsDocumentation AccuracyConfidentiality RegulationsHealthcare Delivery Systems
Soft Skills
Good JudgmentCustomer ServiceOrganizational SkillsOral CommunicationWritten CommunicationPersuasion SkillsNegotiation SkillsCritical Thinking
Tools & Technologies
Word Processing SoftwareMicrosoft OfficeDual Screen Navigation
Certifications & Qualifications
Active RN LicenseNurse Licensure Compact (NLC) Compliance
Industry Keywords
Managed CareHome HealthMedicare Part BClinical DocumentationRegulatory Compliance
About the role
Key responsibilities & impact- Research complex appeal and retrospective review requests, including pre-pay and post-payment review appeals
- Perform clinical reviews or benefit analyses to determine whether requested services meet medical necessity guidelines
- Document appeal or retrospective review bases accurately, timely, and in accordance with regulations or standards
- Research service appeals by members and providers using clinical documentation, contractual requirements, governing agencies, policies, and procedures
- Apply confidentiality regulations regarding protected health information
- Define and determine precedence of pertinent issues when applying policies, procedures, clinical information, and benefit or policy provisions
- Perform special projects, including reviewing clinical information to identify quality-of-care issues
- Complete training lasting approximately 8 to 12 weeks
- Work Monday through Friday, 40 hours per week, in an 8-hour shift within business hours; after training, shifts may begin as early as 6:00 a.m. Eastern Time
Requirements
What you’ll need- Associate's in a job related field
- Graduate of Accredited School of Nursing as a degree equivalency
- Four years of combined experience in clinical, utilization/medical review, quality assurance, or home health experience, including 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience
- 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
- 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
- Microsoft Office proficiency
- Active, unrestricted RN license from the United States and the state of hire, or active compact multistate unrestricted RN license as defined by 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
- Intermediate-level Excel skills
- Experience creating letters and documents by reviewing appeals and extracting information accurately
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