Medical Review Analyst

Blue Cross and Blue Shield of North Carolina • Remote Flex - North Carolina, NC

1d • $73,698 - $117,917 • Hybrid

About The Position

As a Medical Review Analyst, you will identify, analyze, and determine medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims, using varied and broad clinical expertise. The Medical Review Analyst acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits.

Requirements

• RN, PA or NP with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings
• LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings.
• Must hold and maintain a valid North Carolina clinical license.

Nice To Haves

• Demonstrated experience working within a health plan/insurance environment highly preferred.

Responsibilities

• Determines, medical necessity, benefit eligibility and/or appropriate reimbursement allowances for complex claims and/or products by using clinical experience, medical literature, medical records, certificate guidelines, medical policy and several complex and varied computer application software systems.
• Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies (e.g., federal, state and BCBSA etc.).
• Identifies, documents, and escalates system and process problems. Through analysis, determines root cause and recommends possible solutions.
• Defines, communicates and follows up as appropriate on the root causes of errors to others.
• Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria, to determine the medical necessity of the treatment.
• Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries.
• Issues denials according to department protocols.
• Documents outcome of reviews.
• Maintains confidentiality of all PHI in compliance with state and federal laws.
• Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner.
• Identifies situations in which claims filing/coding guidelines are not being followed by providers; documents examples for referral to Network Management and/or Special Investigations for appropriate action.
• Communicates with members and providers to obtain additional information.
• Informs members, providers, and internal customers of claims status and determinations.
• Documents the required clinical information, source and rationale (referencing the appropriate internal and external resources) for decision-making in the appropriate medical management tools.
• Performs post adjudication review of claims related to coding, billing and reimbursement. (FEP and Senior Market, Medicare HMO/PPO)
• Reviews claims for Individual Business for possible misrepresentation as needed.
• Gathers information and prepares documentation for internal review.
• Takes appropriate action based on internal guidelines.

Benefits

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed