Remote RN Medical Reviewer II (Claims & Utilization)

Southcarolinablues; South Carolina; Remote; USD 68,000 - 90,000; Full time

Benefits offered by this job

401k retirement savings plan with 회사 매

Life Insurance

Paid Time Off (PTO)

Education Assistance

Job summary

BlueCross BlueShield of South Carolina is seeking a Remote RN Medical Reviewer II to perform medical reviews using clinical documentation and established guidelines. You will review home health and hospice documentation, determine medical necessity, and support claims and utilization practices in a work-from-home setup.

The role requires an RN license in the hiring state and at least two years of clinical experience.

Qualifications

• Associate Degree – Nursing or graduate of an accredited School of Nursing.
• Two years clinical experience.
• Working knowledge of word processing software.
• Ability to work independently, prioritize effectively, and make sound decisions.
• 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.

Responsibilities

• Performs medical claim reviews for medically complex services, preauthorization/predetermination, appeals, and referrals for fraud/abuse.
• Determines medical necessity and appropriateness for coverage and reimbursement.
• Monitors timeliness of processes according to contractor standards.
• Documents medical rationale to justify payment or denial of services and supplies.
• Educates internal/external staff on medical reviews, terminology, coverage determinations, and coding procedures.
• Participates in quality control activities and supports team objectives.
• Provides guidance to LPN team members and educates non-medical staff through meetings and training.
• Assists with special projects and duties as assigned by management.

Skills

Analytical thinking

Oral and written communication

Customer service

Independent work

Microsoft Office

Word processing software

Education

Associate Degree – Nursing

Graduate of an accredited School of Nursing

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a Remote RN Medical Reviewer II to perform medical reviews using clinical documentation and established guidelines. You will review home health and hospice documentation, determine medical necessity, and support claims and utilization practices in a work-from-home setup.

The role requires an RN license in the hiring state and at least two years of clinical experience.