Remote RN Medical Reviewer II – Claims & Utilization

BlueCross and BlueShield of South Carolina; États-Unis; À distance; USD 65 000 - 80 000; Plein temps

Avantages offerts par ce poste

Subsidized health plans

Dental and vision coverage

401k retirement

Résumé du poste

BlueCross and BlueShield of South Carolina seeks an RN Medical Reviewer II to join the Palmetto GBA Medical Review team. You will perform medical reviews using clinical information, apply guidelines, and help ensure accurate coverage and payment determinations.

Ideal candidates have RN licensure, 2 years of clinical experience, strong communication, and the ability to educate internal/external staff while supporting quality goals. This is a work-from-home, full-time role with daytime hours.

Qualifications

• Associate's degree in a job-related field.
• Degree Equivalency: Graduate of Accredited School of Nursing.

Responsabilités

• Performs medical claim reviews for medically complex services and preauthorization/predetermination.
• Makes payment determinations based on clinical guidelines and criteria.
• Determines medical necessity and coverage/reimbursement.
• Educates staff on reviews, terminology, and coding procedures.
• Supports quality control and team education.

Connaissances

Word processing software

Independent work

Judgment

Customer service

Organizational skills

Oral and written communication

Analytical thinking

Discretion with confidential data

Formation

Associate degree (related field)

Nursing degree equivalency

Outils

Microsoft Office

Description du poste

BlueCross and BlueShield of South Carolina seeks an RN Medical Reviewer II to join the Palmetto GBA Medical Review team. You will perform medical reviews using clinical information, apply guidelines, and help ensure accurate coverage and payment determinations.

Ideal candidates have RN licensure, 2 years of clinical experience, strong communication, and the ability to educate internal/external staff while supporting quality goals. This is a work-from-home, full-time role with daytime hours.