RN Medical Reviewer II - CGS

ourhrconnect; Nashville (TN); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health plans and benefits

401k retirement plan with companymatch

Life Insurance

PTO

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking an experienced RN reviewer to perform medical reviews remotely. You will assess clinical information, document decisions, and support utilization practices while complying with privacy regulations.

The role requires clinical experience, an active RN license, and proficiency with Microsoft Office. A hybrid onsite option may apply for certain candidates.

Qualifications

• Associate's degree in a related field or nursing degree equivalency.
• 2 years clinical experience.
• Active RN license in state hired or active compact multistate RN license.

Responsibilities

• Documents the basis of the appeal or retrospective review following regulations and standards.
• Researches substance of service appeals using clinical documentation, contracts, and policies.
• Performs appeal and retrospective reviews applying policies to clinical information and benefit provisions.
• Conducts special projects reviewing clinical information to identify quality of care issues.

Skills

Analytical thinking

Communication skills

Independent work

Customer service

Education

Associate's degree related field

Nursing degree equivalency

Tools

Microsoft Office

Job description

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

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

CGS Admin - one of BlueCross BlueShield's South Carolina subsidiary companies.

Location

This is a full-time, remote (40-hours/week) working an 8hr shift Monday-Friday within the hours of 8:00am-4:30pm. For candidates selected that live within 40 miles of our Nashville, TN or Columbia, SC locations a hybrid schedule will be followed: 3 days onsite and 2 days remote.

Sponsorship

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

What You'll Do:

• Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
• Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.
• Performs special projects including reviews of clinical information to identify quality of care issues.

To Qualify for This Position, You'll Need:

• Required Education: Associate's in a job related field Degree Equivalency : Graduate of Accredited School of Nursing
• Required Work Experience: 2 years clinical experience
• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgement skills. Demonstrated customer service and organizational skills. Demonstrated customer service, organizational, 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 License and Certificate: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

What We Prefer:

• Preferred Education: Bachelor's degree- Nursing.
• Preferred Work Experience: Work exposure to home health, hospice, case management, and/or utilization
• Preferred Skills and Abilities: Computer literacy
• Preferred Software and Other Tools: Microsoft Office Suite

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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 understand the value of a diverse and inclusive workplace and 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 disabilities and 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 disa