Medical Reviewer II - Palmetto GBA

Palmetto GBA

1d•Remote

About The Position

This position involves performing medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. The role requires documenting decisions based on these guidelines and providing support and review of medical claims and utilization practices. Palmetto GBA, a subsidiary of BlueCross BlueShield of South Carolina, is a healthcare service administrator and one of the nation’s largest providers of high-volume medical claims and transaction processing. The company offers services and technology solutions to improve and streamline healthcare administration for government and corporate entities, requiring a diverse workforce and expertise from data analytics to advanced systems. Palmetto GBA supports employee development through training classes, leadership programs, and tuition assistance, and acknowledges hard work with awards and financial incentives. This is a full-time remote position with an 8-hour shift scheduled during normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday, with occasional overtime as needed. A U.S. Citizenship is required to obtain a security clearance.

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).

Responsibilities

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.