RN Medical Reviewer II (Medicare Part A) - Palmetto GBA

BlueCross BlueShield of South Carolina; Tennessee; Remote; USD 60,000 - 75,000; Full time

Job summary

A leading healthcare organization is seeking a qualified RN for medical claim reviews. You will be responsible for determining coverage necessity, ensuring compliance with guidelines, and educating staff. Ideal candidates possess strong analytical skills and relevant nursing experience. Additional perks include a robust retirement plan and health benefits.

Benefits

401(k) retirement savings plan with company match

Subsidized health plans and free vision coverage

Life insurance

Paid annual leave

Wellness programs and a healthy lifestyle premium discount

Tuition assistance

Qualifications

• Active, unrestricted RN licensure from the United States.
• Two years of clinical nursing experience required.
• Knowledge of CMS guidelines preferred.

Responsibilities

• Performs medical claim reviews for complex services and preauthorizations.
• Documents medical rationale for payment or denial of claims.
• Educates staff on medical reviews and coding procedures.

Skills

Analytical skills

Communication

Customer service

Judgment

Organization

Education

Associates in a job-related field

Tools

Microsoft Office

Job description

Work hours will be 8 : 00 am to 5 : 00 pm Monday through Friday.

You must have high-speed (non-satellite) internet service and a private home office to work from home.

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 :

Required Licenses and Certificates : Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC),

Required Education : Associates in a job-related field OR graduate of Accredited School of Nursing.

Required Work Experience : Two years of clinical nursing experience.

Required Skills and Abilities : Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. 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.

We Prefer That You Have :

• Preferred Work Experience : Five years nursing experience to include one or more of the following : Medical Review, Utilization Review, Quality Assurance, Inpatient Care, ER, Critical Care, Renal, GI, or Cardiac. or Case management experience.
• Software and Tools : Intermediate Excel knowledge. FISS, EMS, iFLOW
• Preferred skills : Knowledge of CMS guidelines and Medicare Part A

W hat We Can Do for You

• 401(k) retirement savings plan with company match
• Subsidized health plans and free vision coverage
• Life insurance
• Paid annual leave — the longer you work here, the more you earn
• Nine paid holidays
• On-site cafeterias and fitness centers in major locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service recognition

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication

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