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RN Corporate Appeals Manager
BlueCross BlueShield of South Carolina. Oversee appeals/case review clinical and support staff, operations, and staff training needs .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical oversight, appeals management, and compliance with regulatory standards such as NCQA and HIPAA. Proven ability to lead teams, develop training programs, and implement quality improvement initiatives in healthcare settings.
Highest-signal resume keywords
Active RN LicensureClinical ExperienceUtilization Review GuidelinesSupervisory ExperienceMicrosoft 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 OversightAppeals ManagementQuality Improvement InitiativesCompliance OversightCost-Containment StrategiesPatient CareDocumentation StandardsData TrackingRegulatory ComplianceTraining Development
Soft Skills
Effective Customer ServiceOrganizational SkillsAnalytical ThinkingPresentation SkillsDecision-Making
Tools & Technologies
Word Processing SoftwareSpreadsheet SoftwarePresentation SoftwareMicrosoft Office
Certifications & Qualifications
Active RN LicensureSocial Worker LicensureCounselor Licensure
Industry Keywords
NCQAHEDISURACDOLDOIHIPAAManaged Care Delivery SystemsQuality StandardsAccreditationCase Review
About the role
Key responsibilities & impact- Oversee appeals/case review clinical and support staff, operations, and staff training needs
- Supervise development and administration of appeals/case review services to meet regulatory, contract, accreditation, and program requirements, including NCQA, HEDIS, URAC, DOL, DOI, and HIPAA
- Identify, develop, and implement quality initiatives, compliance oversight, corrective actions, and required quality-improvement reporting
- Develop and implement tracking, trending, and cost-containment initiatives
- Provide clinical input and direction for advanced and complicated case reviews
- Interface with internal and external customers
- Develop and present appeals/case-review educational programs
- Oversee employee recruitment, hiring, training, and retention strategies
- Ensure documentation, timeliness, quality standards, state and federal compliance, and positive clinical outcomes
Requirements
What you’ll need- Bachelor's in a job-related field required
- Graduate of Accredited School of Nursing accepted as a degree equivalency; equivalency not applicable for the Celerian Group, where a bachelor's degree is required
- 5 years’ clinical experience including direct patient care, appeals, or utilization review
- 2 years supervisory/team lead experience (concurrent) or equivalent military experience in grade E4 or above
- Knowledge/understanding of utilization review guidelines and managed care delivery systems
- Working knowledge of word processing, spreadsheet, and presentation software
- Microsoft Office proficiency
- Active, unrestricted RN licensure from the United States and in the state of hire, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact; alternatively, active unrestricted U.S. and state-of-hire Social Worker or Counselor licensure for Div. 75 only
- Ability to work independently, prioritize effectively, and make sound decisions
- Effective customer service and organizational skills
- Demonstrated presentation skills
- Proficiency in spelling, punctuation, and grammar
- Analytical or critical thinking skills
- Ability to persuade, negotiate, or influence others
- Ability to handle confidential or sensitive information with discretion
- Ability to direct, motivate, and assess performance of others
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