Remote RN Medical Reviewer II – Claims & Coverage

Southcarolinablues; South Carolina; Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Health plans

401k with company match

Life Insurance

Paid Time Off

Education Assistance

Service Recognition

Discounts

Job summary

BlueCross BlueShield of South Carolina seeks an RN Medical Reviewer II to perform medical reviews using clinical guidelines and protocol sets. You will document decisions, support claims reviews and educate staff, working primarily from a home office in a full-time, remote role.

The ideal candidate holds an RN license, an associate degree in nursing, 2 years of clinical experience, and solid MS Office skills.

Qualifications

• Associate degree in a job-related field or nursing degree equivalency.
• 2 years of clinical experience required.
• Proficient with word processing software and MS Office.

Responsibilities

• Performs medical claim reviews for complex services, preauthorization, appeals and fraud/abuse referrals.
• Makes payment determinations based on clinical guidelines and criteria.
• Determines medical necessity and coverage Reasonableness for reimbursement.
• Monitors timeliness and documents medical rationale for decisions.
• Educates internal/external staff on reviews, terminology and procedures.
• Participates in quality control and supports team goals.
• Guides LPN team members and provides education to non-medical staff.
• Assists with special projects as assigned.

Skills

Written communication

Oral communication

Independent work

Decision making

Judgment

Customer service

Organizational skills

Analytical thinking

Education

Associate's degree in Nursing

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina seeks an RN Medical Reviewer II to perform medical reviews using clinical guidelines and protocol sets. You will document decisions, support claims reviews and educate staff, working primarily from a home office in a full-time, remote role.

The ideal candidate holds an RN license, an associate degree in nursing, 2 years of clinical experience, and solid MS Office skills.