RN Medical Reviewer, FEP

Blue Cross & Blue Shield of Mississippi; Flowood (MS); On-site; USD 65,000 - 85,000; Full time

Job summary

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

The role requires an unrestricted RN license in Mississippi, a Bachelor’s degree in Nursing (Master’s preferred) and at least 2 years of clinical experience. Strong analytical, documentation, and MS Office skills are essential for efficient claim adjudication.

Qualifications

• Must have RN licensure in Mississippi.
• Bachelor’s degree in Nursing required; Master’s preferred.
• Minimum 2 years of clinical experience.
• Strong analytical and decision-making abilities.
• Proficient PC skills and MS Office.

Responsibilities

• Conduct clinical review of pre-service requests and post-service claims.
• Determine coverage and medical necessity using policy criteria.
• Request and review clinical documentation to support determinations.
• Document rationale and communicate decisions for claim adjudication.

Skills

Analytical skills

Decision making

Attention to detail

Flexible schedule

Communication skills

Education

Bachelor’s degree in Nursing

Master’s degree in Nursing

Tools

Microsoft Office

Job description

Healthy Careers Start Here

The RN Medical Reviewer, FEP is responsible for thorough clinical review of the Federal Employee Program pre-service requests and post-service claim review for medical and medical drug services. The RN Medical Reviewer, FEP is responsible for determining if the requested service is covered and medically necessary using established Service Benefit Plan and medical policy criteria and by requesting the necessary clinical documentation to make a determination. Once a determination is made, the RN Medical Reviewer, FEP must clearly document the clinical decision and rationale to provide instruction for claim adjudication. The RN Medical Reviewer, FEP is relied upon to identify member and provider utilization trends as well as identify members who may be eligible for Care Management intervention.

Job-Specific Requirements

• Bachelor’s degree in Nursing and RN licensure that is unrestricted in the state of Mississippi.
• Master’s degree in Nursing preferred.
• Minimum 2 years of clinical experience.
• Must possess excellent analytical and decision making skills to review and interpret complex claims and medical information to ensure claims are processed according to Service Benefit Plan provisions and Medical Policy.
• Must be able to work with a high degree of accuracy and attention to detail to ensure work products are of high quality.
• Must be able to work a flexible schedule when required.
• Must have above average PC skills and intermediate knowledge of Microsoft Office.

Blue Cross & Blue Shield of Mississippi is an Equal opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We offer a comprehensive benefits package that is worth approximately one-third of the salary compensation. Our benefits program is among the best in the health care field. We are looking for employees who can bring their experience, expertise and dedication to work for our customers.