RN Medical Reviewer II

Description

Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: Full-time remote position. Works an 8-hour shift during normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday. Occasional overtime may be necessary due to business needs.
Government Clearance: Requires U.S. Citizenship to obtain a security clearance.

What You'll Do

• Performs medical claim reviews for medically complex services, preauthorization/predetermination services, appeals/reconsiderations, referrals for potential fraud and abuse, and corrects 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.
• Maintains process 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 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.
• Affords assistance with special projects and specialty duties/responsibilities as assigned by management.

To Qualify For This Position, You'll Need The Following Required Education And Work Experience

• Required Education: Associate's degree in a job-related field.
• Required Work Experience: 2 years of 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).

What To Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. 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. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.