Medical Reviewer II

BlueCross BlueShield of South Carolina; South Carolina; Remote; USD 65,000 - 85,000; Full time

Job summary

A health insurance company is seeking a qualified candidate to perform medical claim reviews. This role requires an Associate's degree and active RN licensure. Responsibilities include reviewing claims, educating staff, and participating in quality control activities. The position is full-time and offers remote work in South Carolina and nearby states. Comprehensive benefits package including 401(k) and health coverage is available.

Benefits

401(k) retirement savings plan with company match

Subsidized health plans

Tuition assistance

PTO

Wellness programs

Qualifications

• Active RN licensure in state hired or compact multistate license required.
• 2 years clinical experience required.
• Ability to handle confidential information discreetly.

Responsibilities

• Perform medical claim reviews and determinations of medical necessity.
• Educate staff on medical reviews and coding procedures.
• Participate in quality control activities and provide team guidance.

Skills

Analytical thinking

Customer service

Decision making

Oral communication

Written communication

Organization

Education

Associate's degree in a job related field

RN licensure

Tools

Microsoft Office

Job description

Overview

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

Logistic: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

SCA Benefit Requirements

BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O\'Hara Service Contract Act (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.

Location

This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama.

What You\'ll Do

• Perform 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. Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives. Provide 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.

To Qualify For This Position

• Required Education: Associate\'s in a job related field
• Degree Equivalency: Graduate of Accredited School of Nursing.
• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• Required Work Experience: 2 years clinical experience.
• Required Skills and Abilities: 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.
• Required Software and Other Tools: Microsoft Office.

Benefits

Our Comprehensive Benefits Package Includes The Following. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 401(k) retirement savings plan with company match
• Subsidized health plans, dental and vision coverage
• Life insurance
• PTO
• Nine paid holidays
• On-site cafeterias and fitness centers in significant locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service Recognition

What We Can Do For You

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

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 conduct interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

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 [e-mail] 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.