Medical Reviewer II

🔥 0 minutes ago

🏈 Alabama, South Carolina – Remote

🏈 Alabama – Remote 🌴 South Carolina – 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 Insurance

💸 Finance

Healthcare Insurance • Insurance • Finance

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 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 • 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