Medical Reviewer II – Prior-Auth A/B MAC
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Hybrid
Location: Nashville • Hawaii • Tennessee • United States
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Salary
💰 $47,263 - $90,548 per year
About the role
- 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, 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 and 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
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Associate in a job-related field OR graduate of an Accredited School of Nursing
- Two years of clinical nursing 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
- Five years of clinical experience as a Registered Nurse, including two years in specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.
- Ability to work with multiple Windows-based programs simultaneously.
- Intermediate Word, Excel, and Outlook skills.
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 reviewclinical nursing experiencecoding proceduresmedical necessity determinationcharge payment determinationquality control activitiesanalytical skillscritical thinking skillspreauthorizationutilization management
Soft Skills
customer serviceorganizational skillsoral communicationwritten communicationindependent workprioritizationdecision makinggood judgmentdiscretionteam collaboration
Certifications
active RN licensurecompact multistate RN licensegraduate of an Accredited School of Nursing