RN Medical Reviewer II
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
RN Medical Reviewer II performing claims reviews for medically complex services. Supporting healthcare administration for BlueCross BlueShield's subsidiary companies while working remotely.
Responsibilities:
- 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.
Requirements:
- Required Education: Associate's in a job-related field
- Degree Equivalency: Graduate of Accredited School of Nursing.
- Required Work Experience: 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.
- 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
Similar Jobs
Clinical Data Reviewer – Oncology
Clinical Data Reviewer specializing in Oncology at Syneos Health. Ensuring data readiness and conducting clinical reviews for oncology studies.
Reviewer II, Medical
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.
Medical Reviewer
Medical Reviewer overseeing medical review activities for global pharmacovigilance at ICON. Requires expertise in drug safety and the ability to work independently.
Medical Reviewer III – Home Health and Hospice
Medical Reviewer III conducting medical reviews for claims and services at BlueCross BlueShield of South Carolina. Analyzing medical information and educating staff on coverage determinations while ensuring compliance.
Medical Reviewer III – Home Health and Hospice
Medical Reviewer III handling complex medical claim reviews and ensuring compliance with clinical guidelines for BlueCross BlueShield of South Carolina. Join a longstanding insurance leader providing quality service in the healthcare sector.
Clinical Reviewer / Care Manager
Clinical Reviewer managing data collection and communications for patient reviews at Phelps Health. Responsible for authorizations and reviews for Medicare and other third party payers.
Genetic Counselor, Clinical Reviewer
Genetic Counselor Clinical Reviewer responsible for evaluating genetic testing requests and authorizing coverage. Ensuring expert advice is available for physicians and labs regarding genetic testing.
Senior Medical Reviewer
Team Lead for specialty programs, providing guidance and support to medical review staff. Overseeing quality assurance and compliance initiatives at Palmetto GBA, a BlueCross BlueShield subsidiary.
Medical Reviewer – Thai
Join Translated as a Thai medical reviewer focusing on women's health content. Validate medical terminology and ensure clinical soundness and accuracy in publication-ready materials.
Medical Reviewer, Swedish
Swedish medical reviewer ensuring accuracy and safety in women's health content for a global organization. Collaborate on flexible, project-based freelance content validation and review.
Medical Reviewer, Norwegian
Norwegian Medical Reviewer ensuring accuracy and consistency of medical content at Translated. Position involves reviewing specialized women’s health content for correctness and clarity.
Nurse Practitioner, Medical Reviewer – Reasonable Accommodations Program
Nurse Practitioner reviewing medical documentation for Reasonable Accommodations Program. Providing independent review and analysis to support RA determinations under the Rehabilitation Act of 1973.
RN Clinical Reviewer – IDR
Registered Nurse Clinical Reviewer responsible for conducting comprehensive medical-legal reviews remotely for a non-profit organization. Collaborating with administrative and clinical teams to ensure compliance and accurate determination.
Medical Claims Reviewer – Home Health
Medical Claims Reviewer at Broadway Ventures handling medical claims reviews and determinations based on clinical information. Supporting healthcare clients through expert review and decision documentation.
Medical Reviewer, LPN
Medical Reviewer LPN conducting pre-authorization reviews for HCSC. Focusing on utilization review and quality of care compliance.
Physician Clinical Reviewer – Allergy/Immunology
Physician Clinical Reviewer evaluating clinical cases while ensuring medical necessity guidelines compliance at Prime Therapeutics. Collaborates with physicians to resolve determinations and assists with appeals.
Physician Clinical Reviewer – Pediatric Oncologist
Clinical Reviewer for pediatric oncology at Prime Therapeutics, reviewing service requests and helping in clinical decision making. Engaging with healthcare professionals to ensure adherence to medical guidelines as part of utilization management.
Physician Clinical Reviewer – Pediatric Neurology
Physician Clinical Reviewer in pediatric neurology conducting medical reviews and collaborating with health professionals. Ensuring compliance with guidelines and regulations through documentation and communication.
Physician Clinical Reviewer – Urology
Clinical Reviewer for utilization management focusing on Urology. Engaging with physicians and patients to ensure adherence to clinical guidelines and rationales.
Physician Clinical Reviewer – Endocrinology
Physician Clinical Reviewer responsible for medical review of service requests in utilization management. Collaborating with physicians and health plan members to ensure compliance with guidelines.