Healthcare Appeals Analyst, RN

This is a fully remote position, open to applicants in Florida.

📋 Description

• Conduct reviews and research on provider appeals to arrive at final determinations.

• Analyze provider appeals alongside medical documentation.

• Examine CMS-1500 forms or their equivalent electronic versions for correct coding.

• Utilize Legacy or Diamond systems to investigate the initial processing of claims by BCBSF.

• Support appeal coordinators with clinical research and the appeal process adhering to ERISA, HIPAA, and both corporate and departmental standards.

• Interpret BCBSF Medical Coverage Guidelines for team members.

• Work in partnership with the Managing Medical Director to implement modifications to medical coverage guidelines.

• Research, prepare, and present clinical appeal cases to the Provider Appeal Panel.

• Collect data from business partners throughout the organization to inform final determinations.

• Adhere to regulatory mandates, corporate values, policies, and procedures.

• Ensure that final determinations are made and communicated to providers within established timelines.

• Record findings and final determinations in BCBSF systems and SQL databases.

• Draft statements in final provider documents that support the final determination.

⛳️ Requirements

• A minimum of 2 years of relevant clinical work experience.

• A related bachelor's degree or equivalent relevant work experience.

• Active RN state licensure and/or compact state licensure.

• Registered Nurse licensed in Florida.

• Extensive familiarity with Medical Coverage Guidelines related to medical necessity and experimental/investigational procedures.

• Strong ability to interact professionally with both internal and external customers.

• Capability to utilize multiple research and processing systems simultaneously.

• Knowledge of HIPAA and ERISA regulations.

• Understanding of regulatory requirements.

• Ability to operate within tight deadlines.

• Proficient in Microsoft Office Suite, including Word, PowerPoint, and Excel.

• Occasional travel may be necessary to support business operations.

🏝️ Benefits

• Comprehensive medical, dental, vision, life, and global travel health insurance.

• Income protection benefits including life insurance and short- and long-term disability programs.

• Leave programs to accommodate personal needs.

• Retirement Savings Plan with employer matching contributions.

• Paid time off.

• Volunteer time off.

• 10 paid holidays.

• 2 well-being days.

• Additional voluntary benefits available.

• An extensive wellness program.

• Opportunities for incentive or commission-based compensation.

• Regular annual performance reviews with pay considerations for salary increases based on performance.