RN Medical Reviewer III (W@H South Carolina)

Summary

Description

Logistics

This position is full time (40 hours/week) Monday-Friday with an 8-hour shift from 6:00am-5:00pm EST and will be fully remote. Candidates may be asked to report on-site occasionally for trainings, meetings, or other business needs.

What You Will 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.

To Qualify for This Position, You Will Need:

• Graduate of Accredited School of Nursing OR Associate's in a job-related field
• 2 years clinical experience plus 1 year utilization/medical review, quality assurance, or home health experience, OR 3 years of clinical experience. FOR PALMETTO GBS (CO. 033) ONLY: 2 years of clinical experience plus 2 years utilization/medical review quality assurance, or home health experience.
• 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.
• 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 Licenses and Certificates: Active unrestricted RN licensure from the United States and in state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
• Microsoft Office.

What We Prefer:

• Must have well rounded clinical experience.
• Bachelor’s degree in nursing or Graduate of accredited School of Nursing
• 3 years of utilization/medical review, quality assurance, or home health experience, plus 5 years clinical experience
• Must have keen attention to detail.
• Must have proficient level writing skills.
• Knowledge of spreadsheet and database software.
• Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system processing procedures of medical review

What We Can Do for You:

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.

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 a recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here'smore information.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] call 1-800-288-2227, 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.