part time RN Medical Reviewer II (DME Coding) - Palmetto GBA

BlueCross BlueShield of South Carolina

7d•Onsite

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. Logistics: Palmetto GBA- one of BlueCross BlueShield's South Carolina subsidiary companies. Type: Part-time (20 hours/week) Location: Must be within 60 miles of GPC office Key Details: 6-8 weeks on-site training required Schedule: 8:30 AM - 5:00 PM, Monday-Friday (workload dependent) Flexible lunch (30 minutes to 1 hour) Must come in every other week to pick up samples Equipment provided after training

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

Review durable medical equipment samples and applications
Assign HCPCS Level 2 codes
Work in workflow system
Evaluate product applications
Communicate with manufacturers/distributors for additional information
Develop business letters
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 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.