Medical Reviewer II

🔥 0 minutes ago

🏈 Alabama, South Carolina, +1 more states – Remote

🏈 Alabama – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• 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/operations • Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines • Determine medical necessity, appropriateness, and reasonableness for coverage and reimbursement • Monitor process timeliness according to 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-based 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 under 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 • Acute care experience required • Ability to use multiple Windows-based programs simultaneously preferred • Three years of varied RN nursing experience, including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred • Medicare or claims experience a plus • Critical care experience preferred • Medical review/utilization review experience preferred

🏖️ 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 • Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs • Pay differential coverage for full-time employees in the National Guard or Reserves called to active duty