RN Medical Reviewer II

🔥 23 minutes ago

🏈 Alabama – Remote

🏈 Alabama – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

👻 Ghost score 10%

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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 • Make charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines • Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement requirements • Monitor process timeliness according to contractor standards • Document medical rationale supporting payment or denial of services and/or supplies • Educate internal and external staff on medical reviews, terminology, coverage determinations, and coding procedures • Participate in quality control activities supporting corporate and team 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 as assigned by management

🎯 Requirements

• Associate's in a job-related field • Graduate of Accredited School of Nursing • 2 years clinical 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 • Microsoft Office • Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) • Ability to obtain a security clearance • U.S. Citizenship required to obtain the security clearance

🏖️ 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

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