RN Medical Reviewer II - Palmetto GBA in Isle of Palms, SC
Job Description
Summary
Position Purpose: You will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. You will document decisions using indicated protocol sets or clinical guidelines. You will provide support and review of medical claims and utilization practices.
Description
What You’ll Do:
• Performs 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, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.
To Qualify For This Position, You’ll Need
• Associate Degree Nursing OR Graduate of accredited School of Nursing.
• Valid, active, unrestricted RN licensure from the United States and in the state of hire OR active compact multi-state unrestricted RN licensure as defined by the Nurse Licensure Compact (NLC).
• Two years of clinical nursing experience.
We Prefer That You Have
• Medical Review, Utilization Review, Quality Assurance or Case management experience.
• Nursing experience in inpatient rehabilitation or home health.
• Familiar Medicare CMS guidelines.
• Current AAPC Certified Coder certification
• Skilled Nursing Facility (SNF) experience
What We Can Do For You
Our comprehensive benefits package includes:
• 401(k) retirement savings plan with company match
• Subsidized health plans and free vision coverage
• Life insurance
• Paid annual leave — the longer you work here, the more you earn
• Nine paid holidays
• On-site cafeterias and fitness centers in major locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service recognition
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.
Some states have required notifications. Here's more information.
Position Purpose: You will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. You will document decisions using indicated protocol sets or clinical guidelines. You will provide support and review of medical claims and utilization practices.
Description
What You’ll Do:
• Performs 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, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.
To Qualify For This Position, You’ll Need
• Associate Degree Nursing OR Graduate of accredited School of Nursing.
• Valid, active, unrestricted RN licensure from the United States and in the state of hire OR active compact multi-state unrestricted RN licensure as defined by the Nurse Licensure Compact (NLC).
• Two years of clinical nursing experience.
We Prefer That You Have
• Medical Review, Utilization Review, Quality Assurance or Case management experience.
• Nursing experience in inpatient rehabilitation or home health.
• Familiar Medicare CMS guidelines.
• Current AAPC Certified Coder certification
• Skilled Nursing Facility (SNF) experience
What We Can Do For You
Our comprehensive benefits package includes:
• 401(k) retirement savings plan with company match
• Subsidized health plans and free vision coverage
• Life insurance
• Paid annual leave — the longer you work here, the more you earn
• Nine paid holidays
• On-site cafeterias and fitness centers in major locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service recognition
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.
Some states have required notifications. Here's more information.
Job Details
Employment Type
Full-time
Required License
RN (Registered Nurse)
Years of Experience
Intermediate
Work Setting
Office
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About BlueCross BlueShield of SouthCarolina
BlueCross BlueShield of South Carolina is the largest health insurance company in South Carolina, with a proud history dating back to 1946. As an independent licensee of the Blue Cross and Blue Shield Association, the company offers security and stability to the Palmetto State. BlueCross BlueShield administers government contracts and operates sophisticated data processing centers, along with a diverse family of subsidiary companies. The company provides comprehensive benefits to its full-time employees, including retirement savings, health plans, life insurance, and educational assistance. With a corporate culture of community support, BlueCross actively contributes to numerous nonprofit organizations. Committed to diversity and equal opportunities, BlueCross BlueShield of South Carolina welcomes applications from all qualified individuals, without discrimination based on various factors. If you are looking to join a reputable company with deep roots in the community and a focus on innovation, consider a career at BlueCross BlueShield of South Carolina.