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Medical Reviewer II
BlueCross BlueShield of South CarolinaPerform medical reviews using clinical information for BlueCross BlueShield's subsidiary companies. Document decisions based on clinical guidelines and support medical claims and utilization practices.
About the role
Key responsibilities & impact- 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
What you’ll need- 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.
Benefits
Comp & perks- 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
ATS Keywords
✓ Tailor your resumeApplicant 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 proceduresquality controlmedical necessity determinationcoverage reimbursementanalytical skillscritical thinkingcustomer service
Soft Skills
independent workprioritizationsound decision makinggood judgmentorganizational skillsoral communicationwritten communicationdiscretionteam collaborationeducational skills
Certifications
active RN licensurecompact multistate RN licenseAssociate degree - Nursing