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BlueCross BlueShield of South Carolina

Health insurance and plan administration

RN Appeals Analyst

Full-TimePosted on 10/21/2026Deadline 10/25/26
$53.5k - $102.3k+ Incentive Plan + Merit Plan + 401(k) match
Junior
Bachelor's, Associate's
South Carolina, USA
RemoteEmployees must have lived in the US for at least 3 of the last 5 years.
Medical, Clinical & Veterinary

About the job

Requirements
  • An associate degree in Nursing or graduation from an accredited school of nursing is required.
  • Two years of clinical experience plus one year of utilization/medical review, quality assurance, or home health experience, or three years of clinical experience, is required.
  • Working knowledge of word processing software is required.
  • Ability to work independently, prioritize effectively, and make sound decisions is required.
  • Working knowledge of managed care and various forms of health care delivery systems is required.
  • Strong clinical experience including home health, rehabilitation, and/or broad medical-surgical experience is required.
  • Knowledge of specific criteria and protocol sets and their use is required.
  • Good judgment skills are required.
  • Demonstrated customer service, organizational, oral, and written communication skills are required.
  • Ability to persuade, negotiate, or influence others is required.
  • Analytical or critical thinking skills are required.
  • Ability to handle confidential or sensitive information with discretion is required.
  • An active, unrestricted United States registered nurse license in the state of hire, or an active compact multistate unrestricted registered nurse license under the Nurse Licensure Compact, is required.
  • Employees must have lived in the United States for at least three of the last five years to meet the Centers for Medicare and Medicaid Services residency requirement.
Responsibilities
  • Document the basis of appeals or retrospective reviews accurately, promptly, and in accordance with applicable regulations or standards.
  • Research member and provider service appeals using clinical documentation, contractual requirements, governing agency rules, policies, and procedures, while complying with protected health information confidentiality regulations.
  • Perform appeal and retrospective reviews, determining the precedence of pertinent issues when applying policies and procedures to clinical information or benefit and policy provisions.
  • Perform special projects, including reviewing clinical information to identify quality-of-care issues.
Desired Qualifications
  • Three years of utilization/medical review, quality assurance, or home health experience, plus five years of clinical experience.
  • A Bachelor's degree in Nursing.
  • Knowledge of the Administrative Law Judge process.
  • Knowledge of statistical principles.
  • Knowledge of the National Committee for Quality Assurance.
  • Knowledge of the Utilization Review Accreditation Commission.
  • Knowledge of the South Carolina Department of Insurance.
  • Knowledge of United States Department of Labor and Health Insurance Portability and Accountability Act standards and regulations.
  • Knowledge of claims systems.
  • Presentation skills.

About the company

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BlueCross BlueShield of South Carolina

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BlueCross BlueShield of South Carolina is a South Carolina-owned mutual health insurer and health-plan administrator. It offers individual, employer, Medicare and other coverage while operating provider networks, member services, claims and administrative programs. The organization also supports government and commercial health contracts through related businesses and specialized operations. This profile refers specifically to the South Carolina company, not the national Blue Cross Blue Shield Association, and centers on its role connecting members, employers, healthcare providers and public programs.

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