LPN Medical Reviewer
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Remote
Location: South Carolina • United States
Visit company websiteExplore more
About the role
- Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals.
- Documents decisions using indicated protocol sets or clinical guidelines.
- Provides support and review of medical claims and utilization practices.
- Monitors process's timeliness in accordance with contractor standards.
- Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
- Utilizes allocated resources to back up review determination.
- Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
- May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
- Performs screenings/assessments and determines risk via telephone.
- Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
- Provides education to members and their families/caregivers.
- Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.
- Conducts research necessary to make thorough/accurate basis for each determination made.
- Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
- Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
- Participates in quality control activities in support of the corporate and team-based objectives.
Requirements
- Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing
- 2 years clinical experience
- Working knowledge of word processing software
- Good judgment skills
- Demonstrated customer service and organizational skills
- Demonstrated proficiency in spelling, punctuation, and grammar skills
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- Ability to remain in a stationary position and operate a computer
- Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire.
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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical reviewsutilization managementclinical guidelinesauthorization processrisk assessmenteligibility determinationmedical necessitycoding proceduresforecasting researchdocumentation
Soft Skills
good judgmentcustomer serviceorganizational skillsanalytical skillscritical thinkingdiscretioncommunicationeducationtimelinessquality control
Certifications
LPN licenseLVN licenseLBSW license