RN Medical Reviewer III

Summary Performs 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. Description Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies. Remote work eligibility: Georgia and South Carolina residents only • 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, and 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. • 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. Required Education: Associate's in a job related field Degree Equivalency: Graduate of Accredited School of Nursing Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience. Required Skills and Abilities: • Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. • Knowledge of specific criteria/protocol sets and the use of the same. • 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. • Ability to persuade, negotiate, or influence others. • Analytical or critical thinking skills . • Ability to handle confidential or sensitive information with discretion. Required Software and Tools: • Microsoft Office. Required Licenses and Certificates: • Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. Preferred Education: • Bachelor's degree-Nursing or Graduate of accredited School of Nursing. Preferred Work Experience: • 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical experience. Preferred Skills and Abilities: • Knowledge of spreadsheet and database software. • Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review. Preferred Software and Other Tools: • Working knowledge of Microsoft Excel, Access, or other spreadsheet database software. Work Environment: • Typical office environment. • May work from home. • May involve travel from home to office. • Work may involve remaining in a stationary position and operating a computer. 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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply 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