RN Medical Reviewer II (Medicare Part A) – reputed company, Multiple Locations

R1046610 W@H Alabama W@H Kentucky W@H reputed company W@H reputed company Carolina W@H Tennessee reputed company We are currently hiring for an RN Medical Reviewer II to join reputed company. In this role as RN Medical Reviewer II, you will reputed company medical reviews using clinical/medical information provided by physicians/providers and established reputed company/protocol sets or clinical guidelines. You will also reputed company support and review of medical claims and utilization practices. Why should you join the reputed company family? Companies come and go, but for more than seven decades we’ve been part of the national landscape, with our reputed company 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 reputed company. 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 reputed company of business strengths. We deliver outstanding service to our customers. If you are dedicated to the reputed company philosophy, consider joi reputed company Logistics: reputed company– one of BlueCross BlueShield’s South Carolina subsidiary companies.

• Work hours will be 8:00 am to 5:00 pm Monday through Friday.
• Work from home position. You must have high-speed (non-satellite) internet service and a private home office to work from home.

SCA Benefit Requirements: reputed company and its subsidiary companies have reputed company with the federal government subject to the Service Contract reputed company (SCA). Under the McNamara-O'Hara Service Contract reputed company (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date. What You Will Do:

• Performs medical claim reviews for one or more of the following: claims for medically reputed company 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 reputed company/protocol sets or clinical guidelines.
• Determines medical necessity, 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 reputed company 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 reputed company and specialty duties/responsibilities as assigned by management.

To Qualify for This Position, You Will Need:

• Required Licenses and Certificates: reputed company, unrestricted RN licensure from the reputed company and in the state of hire, OR reputed company compact multistate unrestricted RN license as defined by the reputed company Licensure Compact NLC),
• Required Education: Associates in a job-reputed company field OR graduate of Accredited School of Nursing.
• Required Work Experience: Two years of clinical nursing experience.
• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and reputed company reputed company. 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.
• Required Software and Tools: reputed company Office.

reputed company Prefer

• Work Experience: Five years of nursing experience in one or a combination of medical review, utilization review, reputed company assurance, inpatient care, ER, critical care, renal, GI, cardiac, or case management.
• Certification: Certified Medical reputed company, CPC, CIC or coding experience.
• Software and Tools: Intermediate reputed company knowledge. FISS, EMS, or iFLOW experience.
• Skills: Knowledge of CMS guidelines and Medicare Part A

reputed company Can Do for You

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free reputed company coverage.
• Life insurance.
• reputed company annual leave – the longer you work here, the more you earn.
• Nine reputed company holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• reputed company Plan.
• Continuing education funds for additional certifications and certification renewal.

Equal Employment Opportunity Statement reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, reputed company, national reputed company, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, reputed company maintains affirmative reputed company programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to reputed company equal opportunities in reputed company phases of the employment process and to reputed company with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-reputed company conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on reputed company. If you need special assistance or an accommodation while seeking employment, please email reputed company.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will reputed company a determination regarding your request for reasonable accommodation on a case-by-case reputed company. We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Apply tot his job Apply To this Job