Palmetto GBA

• Identifying, developing, and implementing process improvements and automation solutions that enhance operational efficiency within the Audit Reimbursement Department. • Evaluates existing policies, procedures, and workflows to recommend improvements. • Collaborates with department stakeholders to streamline operations, reduce manual effort, improve accuracy, and support continuous improvement initiatives. • Compiles data for analysis and prepares reports and presentations for management using applicable programming languages and/or software products. • Reviews system enhancements/upgrades to determine applicability of customer file modification requirements. • Facilitates timely and accurate updates to reference files based on customer requests. • Coordinates testing and debugging of new or modified software. • Creates test matrices and supporting documentation. • Develops and executes formal test plans to ensure delivery of quality software applications. • Monitors software implementations for exceptions and to verify that changes to the systems' operational process had the desired effect. • Identifies and documents systems problems and assists in their resolution.

• Conducts internal and external timely operational, compliance, and financial audits of divisions, departments, providers, and activities of the corporation including evaluation of internal controls • Identifies, documents, and evaluates business risks • Documents issues, the causes of those issues, and their effects on the process/function and the corporation • Drafts recommendations to limit risks and improve processes, functions and activities • Writes audit reports for corporate executive management that clearly and effectively convey engagement evaluations, conclusions, and recommendations • Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance with laws, regulations, and management policies • Conducts testing of corrective actions as identified • Develops detailed reports on each audit conducted • Examines and evaluates financial and information systems, recommending controls to ensure system reliability and data integrity • Conducts special audit studies for management, such as those required to discover controls for prevention of fraud • Prepares reports of findings and recommendations for management • Assists other auditors in completing their assignments as a means of maximizing audit efficiency

• Conducts internal and/or external timely operational, financial, and/or compliance audits • Identifies, documents, and evaluates business risks • Develops written audit programs • Conducts testing and analysis of existing controls • Prepares written work papers to document testing results • Documents issues, the causes of those issues, and their effects on the corporation • Serves as Lead Auditor on more complex audit assignments • Drafts recommendations to limit risks and improve processes • Writes audit reports for corporate executive management • Collects and analyzes data to detect deficient controls, fraud, or non-compliance • Develops detailed reports on each audit conducted • Examines and evaluates financial and information systems, recommending controls • Conducts special audit studies for management • Provides training to and assists other auditors

Role Description Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided. This position is part of the End-Stage Renal Disease QIP Contract. Logistics: - Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies. Functions as a team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. Acts as a resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving. - Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues. - Participates in departmental quality reviews. - Follows a process to ensure quality plan is adhered to and communicated to all parties. - Gives/receives feedback regarding medical review decision making and technical claims processing issues. - Ensures that quality work instructions/forms/documents are developed/revised as needed. - Provides quality service and communicates effectively with external/internal customers in response to inquiries. - Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems. - Participates in compliance initiatives and other directed activities. - Participates/oversees special projects as requested by management. Qualifications - Associate Degree - Nursing OR Graduate of Accredited School of Nursing. Requirements - Four years of clinical experience, OR - Two years of clinical and two years of medical review/utilization review, OR - Combination of health plan, clinical, and business experience totaling four years. Preferred Requirements - ESRD/renal dialysis experience. - Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting. - Three or more years’ education/training/consulting experience related to Dialysis services (may be concurrent). - Three or more years’ experience in quality management coordination related to Dialysis services (may be concurrent). Required Skills and Abilities - Working knowledge of managed care and various forms of healthcare delivery systems. - Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. - Knowledge of specific criteria/protocol sets and the use of the same. - Working knowledge of word processing and spreadsheet software. - Ability to work independently, prioritize effectively, and make sound decisions. - Good judgment skills. - Demonstrated customer service, organizational, and presentation skills. - Demonstrated proficiency in spelling, punctuation, and grammar skills. - Demonstrated oral and written communication skills. - Ability to persuade, negotiate, or influence others. - Analytical or critical thinking skills. - Ability to handle confidential or sensitive information with discretion. - Ability to lead/direct/motivate others. Required Software and Tools - Microsoft Office. Required License and Certificate - 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).

• Conduct internal and/or external operational, financial, and/or compliance audits • Evaluate internal controls and identify business risks • Develop written audit programs and test existing controls • Document testing results and conclusions • Draft recommendations to limit risks and improve processes • Write audit reports for corporate executive management • Analyze data to detect deficient controls or fraud • Conduct special audit studies for management and train other auditors

• Conducts internal and external timely operational, compliance, and financial audits. • Identifies, documents, and evaluates business risks. • Drafts recommendations to limit risks and improve processes. • Writes audit reports for corporate executive management. • Collects and analyzes data to detect deficient controls and fraud. • Develops detailed reports on each audit conducted. • Examines and evaluates financial and information systems. • Conducts special audit studies for management. • Assists other auditors in completing their assignments.

• 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 • 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, and 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 • 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

• Conducts internal and external timely operational, compliance, and financial audits • Identifies, documents, and evaluates business risks • Drafts recommendations to limit risks and improve processes • Writes audit reports for corporate executive management • Collects and analyzes data to detect deficient controls, duplicated effort, fraud, or non-compliance • Conducts testing of corrective actions • Develops detailed reports on each audit conducted • Examines and evaluates financial and information systems • Conducts special audit studies for management • Prepares reports of findings and recommendations for management • Assists other auditors in completing their assignments

• Perform medical claim reviews for 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. • Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. • Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. • Monitors process’s timeliness in accordance with contractor standards. • Document medical rationale to justify payment or denial of services and/or supplies. • Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Participate in quality control activities in support of the corporate and team-based objectives. • Provide 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.

Role Description 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's South Carolina subsidiary companies. - This is a full-time remote position. You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday. It may be necessary, given the business need, to work occasional overtime. - This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. 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. Qualifications - 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 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. - Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). Benefits - 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.