Medical Reviewer III

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

3d•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. This is a fast-paced, highly collaborative remote role within the Data Strategy team. The ideal candidate thrives in a dynamic environment and is comfortable serving as both an independent contributor and an informal resource for peers. The MR III functions as a subject matter expert in data strategy, providing guidance and serving as a knowledge resource for fellow nurses on the team. This role requires ongoing, cross-functional coordination with Operations Analysts throughout the workday. Nurses identify and research providers; analysts execute the corresponding edits. The workflow is highly interdependent, with frequent email communication between teams. Candidates must be comfortable navigating spreadsheets and interpreting reports. Understanding what the data means. The Data Strategy nurses play a central role in generating and managing workload for the Medical Review (MRR) team. Accuracy, reliability, and attention to detail directly impact downstream operations. This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama. Please note that occasional onsite attendance may be required for training and meetings.

Requirements

Associate's in a job related field
Graduate of Accredited School of Nursing.
Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical.
FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health 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.

Nice To Haves

Bachelor's degree-Nursing or Graduate of accredited School of Nursing.
3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical experience.
Knowledge of spreadsheet and database software.
Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review.
Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.

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, correct coding for claims/operations.
Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
Monitors process’s timeliness in accordance with contractor standards.
Document medical rationale to justify payment or denial of services and/or supplies.
Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
Participate in quality control activities in support of the corporate and team-based objectives.
Provide 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.