Appeals Analyst

BlueCross BlueShield of South Carolina

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

Posted 10/2/2026full-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 processes, with proficiency in analyzing clinical documentation and applying healthcare policies. Maintains confidentiality and compliance while effectively communicating and collaborating with stakeholders.

Highest-signal resume keywords

Active RN LicenseClinical Review ExperienceManaged Care KnowledgeAnalytical SkillsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewBenefit AnalysisMedical Necessity GuidelinesHealthcare PoliciesConfidentiality ManagementQuality-of-Care IdentificationCriteria/Protocol KnowledgeDocumentation AccuracyDecision MakingPrioritization

Soft Skills

Customer ServiceOrganizational SkillsOral CommunicationWritten CommunicationJudgment SkillsPersuasion SkillsNegotiation SkillsCritical Thinking

Tools & Technologies

Word Processing SoftwareMicrosoft Office

Certifications & Qualifications

Active RN LicenseNurse Licensure Compact (NLC) License

Industry Keywords

Managed CareHealthcare Delivery SystemsClinical DocumentationAppeals ProcessRetrospective ReviewPre-Pay AppealsPost-Payment Appeals

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 services meet medical necessity guidelines
Document appeal and retrospective review decisions accurately, timely, and in compliance with applicable regulations and standards
Research member and provider service appeals using clinical documentation, contractual requirements, governing agency requirements, policies, and procedures
Apply policies, procedures, clinical information, benefit provisions, and policy provisions to determine pertinent issues and precedence
Maintain confidentiality of protected health information
Perform special projects, including clinical information reviews to identify quality-of-care issues

Requirements

What you’ll need

Associate's degree in a job-related field, or graduate of an accredited school of nursing
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 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 under the Nurse Licensure Compact (NLC)
Ability to work 40 hours per week, Monday-Friday, within 8:00am-5:00pm
Position is not eligible for sponsorship now or in the future

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
Reasonable accommodations for individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs