RN Medical Reviewer II

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

3d•Remote

About The Position

The RN Medical Reviewer II reviews home health and hospice documentation submitted by providers to ensure that it meets program requirements, including requirements for face-to-face encounters, plans of care, and supporting clinical documentation. The role uses clinical and medical information supplied by physicians and providers together with established criteria, protocol sets, or clinical guidelines to review claims and utilization practices, determine coverage and reimbursement, and document decisions and supporting medical rationale. This work-from-home position is suited to nurses with experience in high-intensity clinical settings. The position is with Palmetto GBA, a subsidiary of BlueCross BlueShield of South Carolina. It is a full-time, 40-hour-per-week role, Monday through Friday. Employees working from home must have high-speed, non-satellite internet service and a private home office. Training lasts approximately four weeks, from 8:00 AM to 4:30 PM Eastern Time. After training, associates may set core hours within the business hours of 6:00 AM to 7:00 PM Eastern Time. The position is not eligible for sponsorship now or in the future.

Requirements

Associate degree in nursing or graduation from an accredited school of nursing.
Two years of clinical experience.
Working knowledge of word processing software.
Ability to work independently, prioritize effectively, and make sound decisions.
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.
Active RN licensure in the state of hire, or an active compact multistate RN license as defined by the Nurse Licensure Compact.
Microsoft Office skills.

Nice To Haves

Critical care experience in a high-intensity setting such as an ER or ICU.
Home health and/or hospice experience.
Familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care.

Responsibilities

Perform medical claim reviews for medically complex services, services requiring preauthorization or predetermination, appeals or reconsideration requests, potential fraud or abuse referrals, and correct coding for claims or operations.
Make reasonable charge payment determinations using clinical or medical information and established criteria, protocol sets, or clinical guidelines.
Determine medical necessity, appropriateness, and reasonableness and necessity for coverage and reimbursement.
Monitor process timeliness in accordance with contractor standards.
Document medical rationale supporting payment or denial of services and supplies.
Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures in accordance with contractor guidelines.
Participate in quality control activities supporting corporate and team-based objectives.
Provide guidance, direction, and input to LPN team members as needed.
Educate non-medical staff through discussions, team meetings, classroom participation, and feedback.
Assist with special projects and specialty duties or responsibilities as assigned by management.