Location

This is a full-time position (40 hours/week) Monday through Friday with flexible hours between 7:30 AM and 5:00 PM. The role is fully remote following completion of onsite training at our Columbia SC office (4101 Percival Road Columbia SC 29229). Candidates must be located within two hours of a BlueCross BlueShield of South Carolina office to accommodate occasional in-office visits as needed.

What You Will Do:

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.

• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation contractual requirements governing agencies policies and procedures while adhering to confidentiality regulations regarding protected health information.

• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.

• Performs special projects including reviews of clinical information to identify quality of care issues.

To Qualify for This Position You Will Need the Following:

• Required Education: Associates in a job related field.

• Degree Equivalency: Graduate of Accredited School of Nursing.

• Required Experience: 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 in clinical utilization/medical review quality assurance or home health experience totaling four years.

• Required Skills and Abilities: 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 to include home health rehabilitation and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. 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.

• Required License and Certificate: An 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).

• Required Software and tools: Microsoft Office.

• Work Environment: Typical office environment. Deadline driven environment.

We Prefer That You Have the Following:

• Emergency room ICU experience or broad clinical experience.

• Utilization Management experience.

• Case Management experience.

• Billing or Claims review experience.

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills advance their careers and contribute their unique abilities to the growth of our company.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age race color national origin sex religion veteran status disability weight sexual orientation gender identity genetic information or any other legally protected status. Additionally as a federal contractor the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities pregnant individuals individuals with pregnancy-related conditions and individuals needing accommodations for sincerely held religious beliefs provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment please email or call ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Heres moreinformation.

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