Remote RN Medical Reviewer II - Appeals & Utilization

ourhrconnect; Nashville (TN); Remote; USD 65.000 - 90.000; Vollzeit

Benefits dieser Stelle

Health plans and benefits

401k retirement plan with companymatch

Life Insurance

PTO

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Zusammenfassung

BlueCross BlueShield of South Carolina is seeking an experienced RN reviewer to perform medical reviews remotely. You will assess clinical information, document decisions, and support utilization practices while complying with privacy regulations.

The role requires clinical experience, an active RN license, and proficiency with Microsoft Office. A hybrid onsite option may apply for certain candidates.

Qualifikationen

• Associate's degree in a related field or nursing degree equivalency.
• 2 years clinical experience.
• Active RN license in state hired or active compact multistate RN license.

Aufgaben

• Documents the basis of the appeal or retrospective review following regulations and standards.
• Researches substance of service appeals using clinical documentation, contracts, and policies.
• Performs appeal and retrospective reviews applying policies to clinical information and benefit provisions.
• Conducts special projects reviewing clinical information to identify quality of care issues.

Kenntnisse

Analytical thinking

Communication skills

Independent work

Customer service

Ausbildung

Associate's degree related field

Nursing degree equivalency

Tools

Microsoft Office

Jobbeschreibung

BlueCross BlueShield of South Carolina is seeking an experienced RN reviewer to perform medical reviews remotely. You will assess clinical information, document decisions, and support utilization practices while complying with privacy regulations.

The role requires clinical experience, an active RN license, and proficiency with Microsoft Office. A hybrid onsite option may apply for certain candidates.