RN Medical Reviewer II - Palmetto GBA
Full Time
South Carolina
Posted
Job description
Summary
Job Description Summary
Position Purpose: You will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. You will document decisions using indicated protocol sets or clinical guidelines. You will provide support and review of medical claims and utilization practices.
Description
What You’ll Do:
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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.
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Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
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Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards.
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Documents medical rationale to justify payment or denial of services and/or supplies.
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Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
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Participates in quality control activities in support of the corporate and team-based objectives.
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Provides guidance, direction, and input as needed to LPN team members.
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Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
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Assists with special projects and specialty duties/responsibilities as assigned by management.
To Qualify for This Position, You’ll Need:
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Associate Degree Nursing OR Graduate of accredited School of Nursing.
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Valid, active, unrestricted RN licensure from the United States and in the state of hire OR active compact multi-state unrestricted RN licensure as defined by the Nurse Licensure Compact (NLC).
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Two years of clinical nursing experience.
We Prefer That You Have:
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Medical Review, Utilization Review, Quality Assurance or Case management experience.
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Nursing experience in inpatient rehabilitation or home health.
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Familiar Medicare CMS guidelines.
What We Can Do for You
Our comprehensive benefits package includes:
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401(k) retirement savings plan with company match
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Subsidized health plans and free vision coverage
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Life insurance
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Paid annual leave — the longer you work here, the more you earn
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Nine paid holidays
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On-site cafeterias and fitness centers in major locations
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Wellness programs and a healthy lifestyle premium discount
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Tuition assistance
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Service recognition
What to Expect Next
After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualified candidates, with prioritization given to those candidates who demonstrate the preferred qualifications.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail abilities@bcbssc.com or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
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