RN Medical Reviewer II – RCD Medicare
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Remote
Location: Alabama • South Carolina • United States
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About the role
- 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, and correct coding for claims/operations
- Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines
- Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement
- Monitor process’s timeliness in accordance with contractor standards
- Document medical rationale to justify payment or denial of services and/or supplies
- Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
- Participate in quality control activities supporting corporate and team-based objectives
- Provide guidance, direction, and input as needed to LPN team members
- Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback
- Assist with special projects and specialty duties and responsibilities as assigned by management
Requirements
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Associate degree - Nursing OR Graduate of 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
- Five years of varied RN nursing experience to include: Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred
- Medicare or claims experience a plus
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical claim reviewspreauthorizationclinical medical informationcoding proceduresmedical necessity determinationcoverage and reimbursementquality control activitiesutilization reviewcritical care experiencemedical/surgical experience
Soft Skills
independent workprioritizationsound decision makinggood judgmentcustomer serviceorganizational skillsoral communicationwritten communicationanalytical skillsdiscretion
Certifications
active RN licensurecompact multistate RN licenseAssociate degree - Nursing