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BlueCross BlueShield of South Carolina
BlueCross BlueShield of South Carolina
Asistență medicalăConsultanțăJuridic
BlueCross BlueShield of South Carolina este o organizație mare din domeniul sănătății și un furnizor de asigurări de sănătate care deservește persoane fizice, familii, angajatori și furnizori de servicii medicale. Oferta sa include planuri de acoperire pentru persoane fizice și familii, opțiuni Medicare și planuri de sănătate de grup, susținute de resurse menite să îi ajute pe membri să acceseze și să înțeleagă serviciile medicale. Fondată în 1946, organizația pune accent și pe stiluri de viață mai sănătoase și pe sănătatea comunității, ceea ce o face relevantă pentru cei care caută oportunități într-o organizație de sănătate amplă și bine consolidată.
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Remote RN Appeals Analyst

Review clinical appeals and retrospective cases for BlueCross BlueShield of South Carolina, assessing medical necessity and documenting decisions. Apply benefit guidelines and regulatory standards while handling protected health information confidentially.

USStatele Unite ale Americii
53.462 $ – 102.258 $ / an
RemoteNormă întreagăNivel mediuSeniorLimbă Obligatorie: englezăAnalist

Descriere

  • Investigate complex appeals and retrospective reviews, including prepayment and post-payment cases.
  • Assess clinical records and benefits to determine whether requested services meet medical necessity guidelines.
  • Record decisions within required timeframes and in accordance with applicable regulations and standards.
  • Document the rationale for appeal and retrospective review decisions accurately and promptly.
  • Research member and provider service appeals using clinical records, contract terms, agency guidance, policies, and procedures.
  • Protect confidential health information in accordance with applicable requirements.
  • Conduct appeals and retrospective reviews, identifying which issues take priority when applying policies, procedures, clinical evidence, benefits, and coverage provisions.
  • Complete special projects, including clinical record reviews to identify quality-of-care concerns.

Cerințe

  • Associate degree in nursing or graduation from an accredited nursing school.
  • Two years of clinical experience plus one year in utilization or medical review, quality assurance, or home health; alternatively, three years of clinical experience.
  • Working knowledge of word-processing software.
  • Ability to work independently, set priorities, and make sound decisions.
  • Working knowledge of managed care and different healthcare delivery systems.
  • Strong clinical background, including home health, rehabilitation, and/or broad medical-surgical experience.
  • Knowledge of specific criteria and protocols and how to apply them.
  • Good judgment.
  • Demonstrated customer service, organizational, verbal, and written communication skills.
  • Ability to persuade, negotiate, or influence others.
  • Analytical and critical-thinking skills.
  • Ability to handle confidential or sensitive information discreetly.
  • Active, unrestricted U.S. RN license valid in the state of hire, or an active unrestricted compact multistate RN license under the Nurse Licensure Compact.
  • For certain divisions, CMS residency requirement: lived in the United States for at least three of the past five years.
  • Preferred: Three years of utilization or medical review, quality assurance, or home health experience, plus five years of clinical experience.
  • Preferred: Bachelor's degree in nursing.
  • Preferred: Knowledge of the Administrative Law Judge process, statistical principles, NCQA, URAC, SCDOI, U.S. DOL and HIPAA standards and regulations, claims systems, and presentation skills.
  • Excellent organizational and time-management skills.

Beneficii

  • 401(k) retirement savings plan with company matching.
  • Subsidized health plans and free vision coverage.
  • Life insurance.
  • Paid annual leave, with accrual increasing with tenure.
  • Nine paid holidays.
  • On-site cafeterias and fitness centers at major locations.
  • Wellness programs and a healthy-lifestyle premium discount.
  • Tuition assistance.
  • Service recognition.
  • Incentive plan.
  • Merit plan.
  • Funding for continuing education, additional certifications, and certification renewal.

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Modivcare

Remote Compensation Analyst II at Modivcare

Modivcare
Sponsor pentru viza H1BAsigurare de sănătateAsistență medicalăTransport
USStatele Unite ale Americii
90.000 $ – 105.000 $ / an
RemoteNormă întreagăNivel mediuSeniorLimbă Obligatorie: englezăAnalist

Administer compensation programs, surveys, audits, and incentive planning for Modivcare’s healthcare transportation business. Maintain accurate compensation data and reporting across HR, Payroll, Finance, and HRIS systems.

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