Medical Reviewer II - Palmetto GBA

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

2d•Remote

About The Position

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Requirements

Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
Associate degree - Nursing OR Graduate of an accredited School of Nursing.
Two years of clinical experience as an RN.
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.

Nice To Haves

Five years of varied RN nursing experience to include: Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience, strongly preferred.
Medicare or claims experience a plus.
Ability to use multiple Windows-based programs simultaneously.

Responsibilities

Perform 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, and correct coding for claims/operations.
Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines.
Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement.
Monitor process’s timeliness in accordance with contractor standards.
Document medical rationale to justify payment or denial of services and/or supplies.
Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
Participate in quality control activities supporting corporate and team-based objectives.
Provide guidance, direction, and input as needed to LPN team members.
Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
Assist with special projects and specialty duties and responsibilities as assigned by management.