RN Medical Reviewer II
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Job Description
RN medical reviewer evaluating medical claims and coverage decisions for BlueCross South Carolina’s government-contract insurance operations. Applying clinical guidelines, documenting determinations, and educating staff.
Responsibilities:
- Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding for claims/operations
- Make charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines
- Determine medical necessity, appropriateness, reasonableness, and necessity for coverage and reimbursement
- Monitor process timeliness according to contractor standards
- Document medical rationale supporting payment or denial of services and/or supplies
- Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
- Participate in quality control activities supporting corporate and team-based objectives
- Provide guidance, direction, and input to LPN team members
- Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
- Assist with special projects and specialty duties assigned by management
Requirements:
- Associate's degree in a job-related field
- Graduate of Accredited School of Nursing as degree equivalency
- 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
- Microsoft Office
- Active RN licensure in the state of hire, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- High-speed (non-satellite) internet service and a private home office
- Position is not eligible for sponsorship now or in the future
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
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