RN Medical Reviewer, FEP

Blue Cross & Blue Shield of Mississippi • Flowood, MS

4d

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
• 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 a determination.
• Clearly document clinical decisions and rationale for claim adjudication.
• Identify member and provider utilization trends.
• Identify members who may be eligible for Care Management intervention.

Benefits

• Comprehensive benefits package that is worth approximately one-third of the salary compensation
• Benefits program is among the best in the health care field

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level