RN Medical Reviewer — Claims & Coverage Expert

bcbsms; Flowood (MS); On-site; USD 70,000 - 100,000; Full time

Job summary

Blue Cross & Blue Shield of Mississippi is seeking an RN Medical Reviewer for the Federal Employee Program (FEP) to conduct thorough clinical reviews of pre-service requests and post-service claims for medical and medical drug services.

The role requires a Mississippi RN license, a Bachelor’s degree in Nursing (Master’s preferred), at least two years of clinical experience, and strong analytical, decision-making, and documentation skills to determine coverage and medical necessity.

Qualifications

• Bachelor’s degree in Nursing and RN licensure unrestricted in Mississippi.
• Master’s degree in Nursing preferred.
• Minimum 2 years of clinical experience.
• Excellent analytical and decision-making skills to review complex claims and medical information.
• High accuracy and attention to detail to ensure work products are of high quality.
• Flexible schedule when required.
• Above-average PC skills and intermediate knowledge of Microsoft Office.

Responsibilities

• Conduct thorough clinical review of FEP pre-service requests and post-service claims for medical and medical drug services.
• Determine if the requested service is covered and medically necessary using policy criteria and by requesting necessary documentation.
• Document clinical decision and rationale to guide claim adjudication.
• Identify member and provider utilization trends and identify members who may be eligible for Care Management intervention.

Skills

Analytical skills

Decision making

Attention to detail

Flexible schedule

Education

Bachelor’s degree in Nursing

RN licensure (Mississippi)

Master’s degree in Nursing (preferred)

Tools

Microsoft Office

Job description

Blue Cross & Blue Shield of Mississippi is seeking an RN Medical Reviewer for the Federal Employee Program (FEP) to conduct thorough clinical reviews of pre-service requests and post-service claims for medical and medical drug services.

The role requires a Mississippi RN license, a Bachelor’s degree in Nursing (Master’s preferred), at least two years of clinical experience, and strong analytical, decision-making, and documentation skills to determine coverage and medical necessity.