RN Appeals Analyst Medicare Part B - CGS

We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South Carolina. In this role as Appeals Analyst, you will research the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Additionally, you will provide thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Lastly, you will document decisions within mandated timeframes and in compliance with applicable regulations or standards. This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Description: Logistics CGS –one of BlueCross BlueShield's South Carolina subsidiary companies. This position is full time (40 hours/week) Monday-Friday 8:00-4:30PM CST and will be W@H OR On-site at One Century Plaza, Nashville TN.

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.