Healthcare Appeals Analyst, RN

GuideWell Source

. Review and research provider appeals to reach a final determination .

Posted 9/30/2026full-timeJacksonville • Florida • United StatesJuniorMid-Level💰 $71,200 - $115,700 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in reviewing provider appeals and medical documentation while ensuring compliance with ERISA and HIPAA regulations. Proficient in utilizing clinical knowledge and coding standards to support final determinations and communicate effectively with stakeholders.

Highest-signal resume keywords

RN - Registered Nurse - State LicensureMedical Coverage Guidelines ExpertiseClinical Research and Appeal ProcessingKnowledge of HIPAA and ERISA RequirementsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ExperienceMedical Documentation ReviewClaims ProcessingSQL Database ManagementCoding StandardsFinal Determination DocumentationProvider Appeal Case PreparationData Gathering for DeterminationsRegulatory ComplianceTime Management

Soft Skills

Professional Customer InteractionCollaboration with Medical DirectorsEffective Communication

Tools & Technologies

Legacy SystemsDiamond SystemBCBSF SystemsMicrosoft WordMicrosoft PowerPointMicrosoft Excel

Certifications & Qualifications

Licensed Registered NurseCompact State Licensure - State of Florida

Industry Keywords

ERISAHIPAAMedical NecessityExperimental ProceduresProvider AppealsClinical AppealsCorporate StandardsProvider Documentation

Tech Stack

Tools & technologies

SQL

About the role

Key responsibilities & impact

Review and research provider appeals to reach a final determination
Review provider appeals and medical documentation
Review CMS-1500 forms or equivalent electronic counterparts for proper coding
Access Legacy or Diamond to review how claims were originally processed by BCBSF
Assist appeal coordinators with clinical research and appeal processing in accordance with ERISA, HIPAA, and corporate/departmental standards
Interpret BCBSF Medical Coverage Guidelines for staff
Collaborate with the Managing Medical Director to facilitate changes to BCBSF Medical Coverage Guidelines
Research, prepare, and present clinical appeal cases to the Provider Appeal Panel
Work with business partners to gather data for final determinations
Follow regulatory requirements and corporate values, policies, and procedures
Ensure final determinations are reached and communicated to providers within strict timelines
Document findings and render final determinations in BCBSF systems and SQL databases
Create statements in final provider documents supporting final determinations

Requirements

What you’ll need

2+ years related work experience, including clinical experience
Related Bachelor’s degree or additional related equivalent work experience
RN - Registered Nurse - State Licensure and/or Compact State Licensure State of Florida
Licensed Registered Nurse
Demonstrated extensive experience with Medical Coverage Guidelines as it relates to medical necessity and experimental/investigational procedures
Demonstrated ability to interact with internal and external customers in a highly professional manner
Demonstrated ability to simultaneously interact with multiple research and processing systems
Knowledge of HIPAA and ERISA requirements
Knowledge of regulatory requirements
Ability to work within strict timeframes
Ability to use Microsoft Office, e.g., Word, PowerPoint, Excel
Sedentary work: exerting up to 10 pounds of force occasionally to move objects

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off
Volunteer time off
10 holidays
2 well-being days
Additional voluntary benefits
Comprehensive wellness program
Opportunities for incentive or commission compensation
Annual reviews with pay for performance considerations for base pay increases