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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
Mid
Bachelor's, Associate's
New Mexico, USA+50 moreMore locations: Washington, USA | Kansas, USA | Pennsylvania, USA | North Dakota, USA | Oregon, USA | Delaware, USA | Iowa, USA | California, USA | Washington, DC, USA | Vermont, USA | Wyoming, USA | Connecticut, USA | Texas, USA | Montana, USA | Florida, USA | New Hampshire, USA | Nevada, USA | South Carolina, USA | South Dakota, USA | Georgia, USA | Arizona, USA | Mississippi, USA | Tennessee, USA | Virginia, USA | Arkansas, USA | Minnesota, USA | Colorado, USA | Nebraska, USA | Rhode Island, USA | Utah, USA | Kentucky, USA | West Virginia, USA | New York, NY, USA | Maryland, USA | Hawaii, USA | Wisconsin, USA | Maine, USA | Massachusetts, USA | North Carolina, USA | Oklahoma, USA | Missouri, USA | Ohio, USA | New Jersey, USA | Indiana, USA | Louisiana, USA | Alaska, USA | Michigan, USA | Illinois, USA | Alabama, USA | Idaho, USA
RemoteRemote, 40 hours/week; Monday–Friday, 8-hour shift within 8:00 a.m.–5:00 p.m. CMS residency requires 3 of the past 5 years living in the U.S.
Medical, Clinical & Veterinary

About the job

Requirements
  • Two years of clinical experience plus one year in utilization or medical review, quality assurance, or home health; alternatively, three years of clinical experience.
  • An Associate Degree in Nursing or graduation from an accredited school of nursing.
  • Working knowledge of word processing software.
  • Working knowledge of managed care and various forms of health care delivery systems.
  • Strong clinical experience, including home health, rehabilitation, and/or broad medical-surgical experience.
  • Knowledge of specific criteria and protocol sets and their use.
  • 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.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • 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.
Responsibilities
  • Document the basis of appeals or retrospective reviews accurately and in a timely manner, in accordance with applicable regulations or standards.
  • Research the substance of member and provider service appeals using clinical documentation, contractual requirements, governing agencies, policies, and procedures, while adhering to confidentiality regulations regarding protected health information.
  • Perform appeal and retrospective reviews, determining the precedence of pertinent issues when applying policies and procedures to clinical information and benefit or policy provisions.
  • Conduct special projects, including reviews of clinical information to identify quality-of-care issues.
Desired Qualifications
  • Three years of utilization or medical review, quality assurance, or home health experience, plus five years of clinical experience.
  • A Bachelor's degree in Nursing.
  • Experience with 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.
  • Excellent organizational and time management 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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