RN Medical Reviewer, FEP

Blue Cross & Blue Shield of Mississippi•Flowood, MS

About The Position

The RN Medical Reviewer, FEP is responsible for thorough clinical review of the Federal Employee Program pre-service requests and post-service claim review for medical and medical drug services. The RN Medical Reviewer, FEP is responsible for determining if the requested service is covered and medically necessary using established Service Benefit Plan and medical policy criteria and by requesting the necessary clinical documentation to make a determination. Once a determination is made, the RN Medical Reviewer, FEP must clearly document the clinical decision and rationale to provide instruction for claim adjudication. The RN Medical Reviewer, FEP is relied upon to identify member and provider utilization trends as well as identify members who may be eligible for Care Management intervention.

Requirements

Bachelor’s degree in Nursing
RN licensure that is unrestricted in the state of Mississippi
Minimum 2 years of clinical experience
Excellent analytical and decision making skills to review and interpret complex claims and medical information
Ability to ensure claims are processed according to Service Benefit Plan provisions and Medical Policy
Ability to work with a high degree of accuracy and attention to detail
Ability to work a flexible schedule when required
Above average PC skills
Intermediate knowledge of Microsoft Office

Nice To Haves

Master’s degree in Nursing

Responsibilities

Conduct thorough clinical review of Federal Employee Program pre-service requests and post-service claim review for medical and medical drug services.
Determine if requested services are covered and medically necessary using established Service Benefit Plan and medical policy criteria.
Request necessary clinical documentation to make determinations.
Clearly document clinical decisions and rationale for claim adjudication.
Identify member and provider utilization trends.
Identify members eligible for Care Management intervention.