RN Medical Reviewer II - CGS

BlueCross BlueShield of South Carolina•Nashville, TN

2d•Remote

About The Position

Performs medical reviews using clinical and medical information provided by physicians and other providers, applying established criteria, protocol sets, or clinical guidelines. Documents review decisions and supports the review of medical claims and utilization practices. The position is with CGS Admin, a BlueCross BlueShield of South Carolina subsidiary. This is a full-time remote role requiring 40 hours per week, with an 8-hour Monday–Friday shift scheduled within 8:00 a.m. to 4:30 p.m. Candidates living within 40 miles of the Nashville, Tennessee, or Columbia, South Carolina locations will follow a hybrid schedule of three onsite days and two remote days. The position is not eligible for current or future sponsorship.

Requirements

Associate's degree in a job-related field, or graduation from an accredited school of nursing as degree equivalency.
Two years of clinical experience.
Working knowledge of word processing software.
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment skills.
Demonstrated customer service, organizational, oral communication, and written communication skills.
Analytical or critical-thinking skills.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office skills.
Active RN licensure in the state of hire, or an active compact multistate RN license as defined by the Nurse Licensure Compact.

Nice To Haves

Bachelor's degree in nursing.
Work exposure to home health, hospice, case management, and/or utilization.
Computer literacy.
Microsoft Office Suite experience.

Responsibilities

Document the basis of appeals or retrospective reviews accurately and promptly, in accordance with applicable regulations or standards.
Research member and provider service appeals using clinical documentation, contractual requirements, governing agency requirements, policies, and procedures, while protecting the confidentiality of protected health information.
Perform appeal and retrospective reviews, identifying and prioritizing pertinent issues when applying policies and procedures to clinical information and benefit or policy provisions.
Conduct special projects, including reviews of clinical information to identify quality-of-care issues.