RN Medical Reviewer II

Palmetto GBA; United States; Remote; USD 68.000 - 90.000; Vollzeit

Benefits dieser Stelle

Subsidized health plans

401k retirement plan

Life Insurance

Paid Time Off (PTO)

Education Assistance

Service Recognition

National discounts

Zusammenfassung

Palmetto GBA, LLC seeks a remote RN reviewer to perform medical claim reviews using clinical information and established guidelines. You will document decisions and support utilization practices from home.

The role requires an RN license, 2+ years of clinical experience, and strong communication and analytical skills. Training is provided, with a 40-hour work week and standard business hours.

Qualifikationen

• Associate degree in nursing or equivalent with RN licensure.
• Two years of clinical nursing experience.
• Proficiency in word processing and Microsoft Office.
• Ability to work independently and manage priorities.
• Strong communication, customer service, and analytical skills.
• Discretion handling confidential information.

Aufgaben

• Review medical claims and determine medical necessity using criteria and guidelines.
• Educate staff on review processes, coding procedures, and coverage determinations.
• Support quality assurance activities and guidance to team members.

Kenntnisse

RN licensure

Clinical experience

Word processing

Independent work

Customer service

Communication

Analytical thinking

Discretion

Ausbildung

Associate Degree – Nursing

Graduate of an accredited School of Nursing

Tools

Microsoft Office

Jobbeschreibung

Summary

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Description

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we’ve been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose

Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Logistics

Palmetto GBA one of BlueCross BlueShield of South Carolina’s subsidiary companies.

Location

This position is full-time (40 hours/week), Monday–Friday, and is Work at Home (W@H). To work from home, you must have high-speed (non-satellite) internet service and a private home office.

Training lasts approximately 4 weeks, 8:00 AM–4:30 PM Eastern Time. After training, associates may set their core hours within our business hours of 6:00 AM–7:00 PM Eastern Time.

Sponsorship

This position is not eligible for sponsorship now or in the future.

What You’ll Do

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

To qualify for this Position, you’ll need the following

Required Education

• Associate Degree – Nursing, OR
• Graduate of an accredited School of Nursing

Required Work Experience

• Two years clinical experience.

Required Skills and Abilities

• 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.

Required Software and Tools

• Microsoft Office

Required Licenses and Certificates

• Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

We Prefer That You Have The Following

• Critical care experience in a high-intensity setting such as ER or ICU
• Home health and/or hospice experience
• Familiarity with home health and hospice documentation requirements, such as face-to-face encounters and plans of care

Our Comprehensive Benefits Package Includes The Following

We offer our employees great benefits and rewards. You will be eligible to participate in our benefits program the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You

We strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here’s moreinformation.

Some states have required notifications. Here’s more information.