RN Medical Reviewer II (Myrtle Beach, Onsite 6 months then Remote)

PGBA,

2d•Hybrid

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. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: 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: PGBA – one of BlueCross BlueShield of South Carolina’s subsidiary companies. Location: This position will be onsite in Myrtle Beach for the training period and then become remote. The hours are Monday through Friday, 8am - 5pm. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

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

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 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.