Medical Reviewer II (W@H Anywhere)
About the position We are currently hiring for a Medical Reviewer II to join BlueCross BlueShield of South Carolina. In this role as a Medical Reviewer II, you will perform 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. Location This position is full-time (40 hours/week) Monday-Friday from 9:00am-9:00pm EST and will be fully remote. 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 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. Requirements • Associates 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). Benefits • Subsidized health plans, dental and vision coverage • 401k retirement savings plan with company match • Life Insurance • Paid Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Education Assistance • Service Recognition • National discounts to movies, theaters, zoos, theme parks and more Apply tot his job