RN Medical Reviewer II

reputed company Performs medical reviews using clinical/medical information provided by physicians/providers and established reputed company/protocol sets or clinical guidelines. Documents reputed company using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. reputed company Logistics: reputed company – one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This is a full-time, remote work-from-home position. reputed company training will be conducted reputed company. Candidates must have reliable high-speed internet service (satellite internet is not permitted) and a private home office or dedicated workspace. The work schedule consists of an 8-hour shift, Monday through Friday, between the hours of 6:00 a.m. and 7:00 p.m. ET. Work schedules will be assigned reputed company these operating hours What You’ll 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 and 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'll Need The Following: Required Education: Associate's in a job-reputed company field Degree Equivalency: Graduate of Accredited School of Nursing. Required Work Experience: 2 years clinical 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. Required Licenses and Certificates: reputed company RN licensure in state reputed company OR reputed company compact multistate RN license as defined by the reputed company Licensure Compact (NLC). We Prefer That You Have The Following: At least 5 years of bedside nursing experience. Clinical experience in Hospice, Home Health, or ICU environments. Prior experience with medical claims review and/or utilization review. Our Comprehensive Benefits Package Includes The Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. Subsidized health plans, dental and reputed company coverage 401k retirement savings plan with company match Life Insurance reputed company 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 reputed company Can Do for You: We understand the value of a diverse and inclusive workplace and reputed company to be an employer where employees across reputed company spectrums have reputed company to reputed company their skills, advance their careers and contribute their unique abilities to the reputed company of reputed company. What To Expect Next: After submitting your application, our reputed company 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. 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 To This Job