RN Medical Reviewer II
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Job Description
RN medical reviewer evaluating complex claims, medical necessity, and coverage decisions for BlueCross BlueShield subsidiary Palmetto GBA. Remote home-office role supporting utilization review and coding operations.
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 or operations
- Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
- Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement
- Monitor process timeliness in accordance with contractor standards
- Document medical rationale supporting payment or denial of services and 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 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:
- Active RN licensure in the state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Associate degree in Nursing OR graduation from an accredited School of Nursing
- Two years of clinical experience as an RN
- 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 proficiency
- High-speed, non-satellite internet service
- Private home office for working from home
- Preferred: five years of varied RN nursing experience including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience
- Medicare or claims experience is a plus
- Preferred: ability to use multiple Windows-based programs simultaneously
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
- Diverse and inclusive workplace with opportunities to develop skills and advance careers
- Reasonable accommodations for individuals with disabilities, pregnancy-related conditions, or sincerely held religious beliefs
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