Remote RN Medical Reviewer II: Claims & Compliance

Southcarolinablues; Alabama; Remote; USD 60.000 - 90.000; Vollzeit

Benefits dieser Stelle

Health insurance

401k with company match

Paid time off (PTO)

Education assistance

Zusammenfassung

BlueCross BlueShield of South Carolina is seeking a RN Medical Reviewer II for a full-time remote position based in Alabama. The role involves reviewing medical claims, determining medical necessity, and ensuring timely processing in line with guidelines.

The ideal candidate holds an RN license (state or compact), an associate degree in a related field, and at least two years of clinical experience. Strong communication and analytical skills are essential, along with proficiency in Microsoft

Qualifikationen

• Associate's degree in a job-related field.
• Graduate of Accredited School of Nursing (RN).
• 2 years clinical experience.
• Working knowledge of word processing software (Microsoft Office).
• 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.

Aufgaben

• Performs medical claim reviews for complex services, preauthorization, appeals, referrals, and potential fraud checks.
• Determines medical necessity and reasonableness for coverage and reimbursement.
• Monitors timeliness against contractor standards.
• Documents medical rationale to justify payment or denial of services.
• Educates internal/external staff on medical reviews and coding procedures.
• Provides guidance to LPN team members and assists with special projects.

Kenntnisse

Word processing

Independent work

Prioritization

Good judgment

Customer service

Organizational skills

Oral and written communication

Analytical thinking

Discretion with sensitive information

Ausbildung

Associate's degree in related field

Nursing degree (RN) from Accredited School

RN licensure in state or multistate compact

Tools

Microsoft Office

Jobbeschreibung

BlueCross BlueShield of South Carolina is seeking a RN Medical Reviewer II for a full-time remote position based in Alabama. The role involves reviewing medical claims, determining medical necessity, and ensuring timely processing in line with guidelines.

The ideal candidate holds an RN license (state or compact), an associate degree in a related field, and at least two years of clinical experience. Strong communication and analytical skills are essential, along with proficiency in Microsoft