RN Appeals Analyst
Nashville, TN · Remote
Summary Researches the substance of complex appeal or retrospective review requests including pre ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
RN Appeals Analyst
Nashville, TN · Remote
Summary Researches the substance of complex appeal or retrospective review requests including pre ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
RN Appeals Analyst
Nashville, TN · Remote
Summary Researches the substance of complex appeal or retrospective review requests including pre ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
RN Appeals Analyst
Nashville, TN · Remote
Summary Researches the substance of complex appeal or retrospective review requests including pre ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
RN Appeals Analyst
Nashville, TN · On-site +1
Summary Researches the substance of complex appeal or retrospective review requests including pre ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
RN Appeals Analyst
Nashville, TN · On-site +1
Summary Researches the substance of complex appeal or retrospective review requests including pre ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required.
Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required.
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required.
Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required.
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Summary We are currently hiring for an Appeals Analyst to join BlueCross BlueShield of South ... An active, unrestricted RN license from the United States and in the state of hire, OR, active ...
Denials Manager RN
San Gabriel, CA · On-site
$53.10/hr
Overview The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to ...
Denials Manager RN
San Gabriel, CA · On-site
$53.10/hr
Overview The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to ...
Overview The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to ...
Overview The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to ...
Denials Manager RN
$53.10 - $58.39/hr
The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to resolve ...
Denials Manager RN
$53.10 - $58.39/hr
The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to resolve ...
... appeals for denied prior authorizations. Includes standard and expedited cases, inpatient ... Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact ...
... appeals for denied prior authorizations. Includes standard and expedited cases, inpatient ... Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact ...
Clinical Appeals-RN
Syracuse, NY · On-site
The Clinical Appeals RN performs the clinical appeals in accordance with internal policy and procedures, as well as regulations and timeframes set forth by the New York State Medicaid Contract. The ...
Clinical Appeals-RN
Syracuse, NY · On-site
The Clinical Appeals RN performs the clinical appeals in accordance with internal policy and procedures, as well as regulations and timeframes set forth by the New York State Medicaid Contract. The ...
(RN) Appeals Medical Review Nurse - REMOTE- PST Schedule
Long Beach, CA · On-site +1
$26.14 - $56.64/hr
... appeals for denied prior authorizations. Includes standard and expedited cases, inpatient ... Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact ...
(RN) Appeals Medical Review Nurse - REMOTE- PST Schedule
Long Beach, CA · On-site +1
$26.14 - $56.64/hr
... appeals for denied prior authorizations. Includes standard and expedited cases, inpatient ... Registered Nurse (RN). License must be active and unrestricted in state of practice. Compact ...
APPEALS COORDINATOR
Prince Frederick, MD · On-site
$23 - $28.75/hr
The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
APPEALS COORDINATOR
Prince Frederick, MD · On-site
$23 - $28.75/hr
The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
APPEALS COORDINATOR
Prince Frederick, MD · On-site
$23 - $28.75/hr
The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
APPEALS COORDINATOR
Prince Frederick, MD · On-site
$23 - $28.75/hr
The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
APPEALS COORDINATOR
Prince Frederick, MD · On-site
$23 - $28.75/hr
The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
APPEALS COORDINATOR
Prince Frederick, MD · On-site
$23 - $28.75/hr
The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
Work closely with RN Appeals Management Nurse and Physician Advisors to optimize appeals for denied Inpatient hospitalizations via administrative assistant supporting including but not limited to ...
Work closely with RN Appeals Management Nurse and Physician Advisors to optimize appeals for denied Inpatient hospitalizations via administrative assistant supporting including but not limited to ...
Rn Appeals information
What are RN Appeals?
RN Appeals are processes handled by Registered Nurses (RNs) who review and manage appeals for denied healthcare claims or services. These nurses use their clinical expertise to assess whether medical care meets insurance guidelines and to advocate for patients by providing additional information or justification for coverage. RN Appeals professionals work with insurance companies, healthcare providers, and patients to ensure that appeals are thoroughly evaluated and that patients receive the care they need when medically appropriate.
How to make $300,000 as a nurse?
Registered nurses (RNs) can earn $300,000 annually by gaining specialized certifications, working in high-paying fields like anesthesia or nurse practitioner roles, and taking on overtime or per diem shifts. Advanced education, experience, and working in regions with higher pay scales can also contribute to higher earnings.
How to become an appeals nurse?
To become an appeals nurse, you typically need to hold a registered nurse (RN) license, which requires completing an accredited nursing program and passing the NCLEX-RN exam. Experience in case management, clinical review, or healthcare reimbursement can be beneficial, along with strong communication and critical thinking skills. Some employers may also prefer certifications such as the Certified Case Manager (CCM).
What are some of the most common challenges faced by RNs working in appeals, and how can they prepare for them?
RNs working in appeals often face the challenge of interpreting complex medical records and insurance policies while advocating for patient coverage. They must balance clinical expertise with a thorough understanding of payer requirements and regulatory guidelines. To prepare, it's helpful to stay current with payer policies, strengthen written communication skills for crafting clear and concise appeal letters, and develop time-management strategies to handle multiple cases simultaneously. Collaborating closely with other healthcare professionals and case managers can also support effective and successful appeals.
What are the key skills and qualifications needed to thrive as an RN Appeals nurse, and why are they important?
To thrive as an RN Appeals nurse, you need a valid RN license, strong clinical knowledge, and an understanding of insurance and utilization review processes. Familiarity with medical review software, electronic health records (EHRs), and regulatory guidelines such as Medicare and Medicaid is essential. Excellent written communication, analytical thinking, and attention to detail are crucial soft skills for crafting persuasive appeals and collaborating with healthcare teams. These skills ensure accurate, timely, and effective appeal submissions that support patient access to necessary care and compliance with payer requirements.
What is the difference between Rn Appeals vs Rn Case Manager?
| Aspect | Rn Appeals | Rn Case Manager |
|---|---|---|
| Credentials | Registered Nurse (RN) license, knowledge of appeals process | Registered Nurse (RN) license, case management certification often preferred |
| Work Environment | Insurance companies, healthcare organizations, legal settings | Hospitals, clinics, insurance companies, community health |
| Employer & Industry | Insurance providers, healthcare agencies | Healthcare providers, insurance companies |
| Primary Focus | Reviewing and appealing denied claims or services | Coordinating patient care, managing cases, ensuring appropriate services |
While both Rn Appeals and Rn Case Managers are registered nurses working in healthcare-related fields, Rn Appeals primarily focus on reviewing and contesting denied insurance claims or services. Rn Case Managers, on the other hand, coordinate patient care and manage cases to ensure appropriate treatment. Understanding these differences helps in choosing the right career path or job search focus.
What does an appeals RN do?
An appeals RN reviews denied insurance or healthcare claims to determine if they should be approved upon appeal. They analyze medical records, policy guidelines, and clinical documentation to support or contest claim decisions, often working closely with healthcare providers and insurance companies. Strong knowledge of medical coding, documentation, and healthcare regulations is essential for this role.
What to do if I don't want to be a nurse anymore?
If you are an RN and no longer want to work as a nurse, you can consider transitioning to related roles such as healthcare administration, medical coding, or teaching. You may need to update your certifications or pursue additional training depending on the new career path you choose.
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Full-time
Medical, Dental, Vision, Life, Retirement, PTO
Posted 2 days ago
Job description
Summary
Researches the substance of complex appeal or retrospective review requests including pre-pay and post-payment review appeal requests. Provides thorough clinical review or benefit analysis to determine if the requested services meet medical necessity guidelines. Documents decisions within mandated timeframes and in compliance with applicable regulations or standards.
Description
Logistics: CGS -one of BlueCross BlueShield's South Carolina subsidiary companies.
Location
This position is full time (40 hours/week) Monday-Friday from 8:00am - 5:00pm and will be fully remote.
What You'll Do:
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.
To Qualify for This Position, You'll Need the Following:
Required Education: Associate's in a job-related field
Degree Equivalency: Graduate of Accredited School of Nursing
Required Work Experience: 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health, OR, 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience or a combination of experience in clinical, utilization/medical review, quality assurance or home health experience totaling four years.
Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. 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.
Required Software and Tools: Microsoft Office.
Required License and Certificate: An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
We Prefer That You Have the Following:
Preferred Education: Bachelor's degree- Nursing.
Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical.
Preferred Skills and Abilities: Administrative Law Judge (ALJ) process.
Knowledge of statistical principles.
Knowledge of the National Committee for Quality Assurance (NCAG).
Knowledge of Utilization Review Accreditation Commission (URAC).
Knowledge of South Carolina Department of Insurance (SCDOI).
Knowledge of US DOL and Health Insurance Portability/Accountability Act (HIPAA) standards/regulations.
Excellent organizational and time management skills. Knowledge of claims systems. Presentation skills.
Preferred Software and Other Tools: Excel or other spreadsheet software. Ability to effectively use Microsoft Office applications, such as Word, Power point and Excel.
Our Comprehensive Benefits Package Includes the Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.comor call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
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