Reviewer II, Medical
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Job Description
Reviewer II, Medical performing medical reviews for claims in a remote role with BlueCross BlueShield. Requires nursing licensure and clinical experience for this full-time position.
Responsibilities:
- Perform 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
- Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
- Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
- Monitors process’s timeliness in accordance with contractor standards
- Document medical rationale to justify payment or denial of services and/or supplies
- Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
- Participate in quality control activities in support of the corporate and team-based objectives
- Provide 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
Requirements:
- Associate's in a job related field
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- 2 years clinical experience
- 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
- Proficiency in Microsoft Office
Benefits:
- 401(k) retirement savings plan with company match
- Subsidized health plans, dental and vision coverage
- Life insurance
- Paid Time Off (PTO)
- Nine paid holidays
- On-site cafeterias and fitness centers in significant locations
- Wellness programs and a healthy lifestyle premium discount
- Tuition assistance
- Service Recognition
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