RN Medical Reviewer II - Palmetto GBA-13

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

1d•Remote

About The Position

The RN Medical Reviewer II performs medical reviews using clinical and medical information provided by physicians and other providers, applying established criteria, protocol sets, or clinical guidelines. The role documents decisions and supports the review of medical claims and utilization practices. It uses clinical expertise to help ensure accurate and timely coverage and payment determinations, and shares knowledge by educating internal and external staff while supporting team quality goals. This is a full-time, salaried, work-at-home position with Palmetto GBA, a subsidiary of BlueCross BlueShield of South Carolina. The schedule is Monday through Friday, with an eight-hour shift during normal business hours of 8:00 AM–5:00 PM ET. Additional hours may occasionally be required based on business needs. The employee must have high-speed, non-satellite internet and a private home office. The position is not eligible for current or future sponsorship.

Requirements

Associate's degree in a job-related field; degree equivalency is 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.
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 skills.
Active RN license in the state of hire, or an active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
High-speed, non-satellite internet service and a private home office.

Responsibilities

Perform medical claim reviews for medically complex services; services requiring preauthorization or predetermination; appeals or reconsiderations; referrals for potential fraud or abuse; and correct coding for claims or operations.
Make reasonable charge payment determinations based on clinical or medical information and established criteria, protocol sets, or clinical guidelines.
Determine medical necessity and appropriateness, and/or 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/or supplies.
Educate internal and external staff about medical reviews, medical terminology, coverage determinations, and coding procedures in accordance with contractor guidelines.
Participate in quality control activities supporting corporate and team 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.