RN Medical Reviewer II

🔥 1 hour ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

👻 Ghost score 10%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Review home health and hospice documentation submitted by providers for program requirements, including face-to-face encounters, plans of care, and supporting clinical documentation • Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and coding accuracy • Make charge payment determinations using clinical information and established criteria, protocols, or clinical guidelines • Determine medical necessity, appropriateness, reasonableness, and coverage/reimbursement necessity • Monitor review timeliness according to contractor standards • Document medical rationale supporting payment or denial of services and 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 assigned by management

🎯 Requirements

• Associate Degree – Nursing, OR graduate of an accredited School of Nursing • Two years clinical experience • Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) • Working knowledge of word processing software • Ability to work independently, prioritize effectively, and make sound decisions • 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 • High-speed non-satellite internet service • Private home office • Position is not eligible for sponsorship now or in the future • Preferred: Critical care experience in a high-intensity setting such as ER or ICU • Preferred: Home health and/or hospice experience • Preferred: Familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care

🏖️ 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 • Opportunity to develop skills, advance careers, and contribute to company growth

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