Appeals & Grievance Nurse Analyst

We are hiring an Appeals & Grievance Nurse Analyst at BCBST! In this role, you will review and process appeals submitted by members and providers, ensuring timely and accurate resolution in compliance with CMS, Medicare, and TennCare guidelines. You will evaluate cases, determine next steps, and manage multiple priorities while meeting strict turnaround times. You will also review clinical and medical records, summarize findings for Medical Director review, and operate within turnaround times as short as 24-72 hours. Your work will play a critical role in maintaining regulatory compliance, improving member experience, and supporting high-quality outcomes through detailed case analysis and effective use of digital tools. To be successful in this role, you'll bring strong analytical skills, attention to detail, and a customer-focused approach. You will be a strong candidate if you have knowledge of Medicare, CMS, and TennCare regulations, along with experience in appeals and grievance processes. Clinical knowledge, strong data entry accuracy, case management skills, and experience (or interest) in using AI tools such as Copilot to improve efficiency will further strengthen your candidacy. Note • This is a fully remote role with a 40-hour workweek; flexibility is required based on business needs, including potential weekend coverage • Sponsorship is not available for this role Job Responsibilities Ensures timeliness and quality is met per regulations/guidelines. Utilize multiple systems in order to appropriately research and document the substance and validity of the appeal or QOC grievance. Evaluate and research medical necessity documentation submitted for clinical review including complex situations. Conduct outreach as applicable for clinical information and preparing case files for the Medical Director to review. Create detailed member and provider specific individualized appeal and QOC grievance response letters; assess appeal and QOC grievance response letters for accuracy and compliance as well as providing recommendations for improvement, if needed. Work collaboratively with the clinical and non-clinical staff for appropriate resolution of appeals and quality of care cases. Job Qualifications Experience 3 years - Clinical nursing experience required Skills\Certifications Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability. Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) Must be a team player, be organized and have the ability to handle multiple projects Excellent oral and written communication skills Strong interpersonal and organizational skills License Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law. Number of Openings Available 1

Worker Type:

Employee Company:

BCBST BlueCross BlueShield of Tennessee, Inc. Applying for this job indicates your acknowledgement and understanding of the following statements: BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page: BCBST's EEO Policies/Notices BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means. As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow. At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability. We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST. We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members. BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based. BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense. If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance.