[Hiring] RN Medical Reviewer II @BlueCross BlueShield of South Carolina

Role Description

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.

Location: This is a full-time remote position. You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday. It may be necessary, given the business need, to work occasional overtime.

Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

What You'll Do:

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.

Qualifications

• Required Education: Associate's in a job-related field.
• Degree Equivalency: Graduate of Accredited School of Nursing.
• Required Work Experience: 2 years clinical experience.
• Required Skills and Abilities:
  • Working knowledge of word processing software.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgment skills.
  • Demonstrated customer service and organizational skills.
  • Demonstrated oral and written communication skills.
  • Analytical or critical thinking skills.
  • Ability to handle confidential or sensitive information with discretion.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Benefits

• 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.