RN Appeals Analyst – SC, GA

BlueCross BlueShield of South Carolina

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

Posted 10/23/2026full-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 documentation and compliance within healthcare regulations. Possesses an active RN license and the ability to analyze clinical information effectively while maintaining confidentiality.

Highest-signal resume keywords

Active RN LicenseClinical ReviewUtilization ReviewMicrosoft Office ProficiencyAnalytical Thinking

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ExperienceBenefit AnalysisMedical Necessity GuidelinesQuality AssuranceHome Health ExperienceDocumentation CompliancePolicy ApplicationContractual RequirementsCriteria/Protocol KnowledgePre-Pay and Post-Payment Review

Soft Skills

Good JudgmentOrganizational SkillsOral CommunicationWritten CommunicationCustomer Service

Tools & Technologies

Word Processing SoftwareManaged Care Systems

Certifications & Qualifications

RN LicenseNurse Licensure Compact (NLC) Compliance

Industry Keywords

Healthcare Delivery SystemsConfidentiality RegulationsClinical DocumentationAppeal ProcessesRetrospective Review

About the role

Key responsibilities & impact

Research the substance of complex appeal and retrospective review requests, including pre-pay and post-payment review appeals
Perform clinical review or benefit analysis to determine whether requested services meet medical necessity guidelines
Document decisions within mandated timeframes and in compliance with applicable regulations or standards
Document the basis of appeals or retrospective reviews accurately and timely
Research member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures
Adhere to confidentiality regulations regarding protected health information
Perform appeal and retrospective reviews by applying policies, procedures, clinical information, and benefit or policy provisions
Perform special projects, including reviews of clinical information to identify quality-of-care issues

Requirements

What you’ll need

Associates in a job-related field
Graduate of Accredited School of Nursing
2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical
For Palmetto GBA (Co. 033) only: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience, or a combination of experience 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
Microsoft Office proficiency
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)
Ability to work independently, prioritize effectively, and make sound decisions
Good judgment, analytical or critical thinking, customer service, organizational, oral and written communication skills
Ability to persuade, negotiate, or influence others
Ability to handle confidential or sensitive information with discretion

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