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BlueCross BlueShield of South Carolina logo
BlueCross BlueShield of South Carolina

South Carolina’s largest and oldest health insurance company

RN Medical Reviewer III

Medical ReviewerMedical ReviewerFull TimeRemoteSeniorTeam 10,001+Since 1946H1B No SponsorCompany SiteLinkedIn

Location

South Carolina

Posted

65 days ago

Salary

0

Seniority

Senior

Associate Degree3 yrs expExperience acceptedEnglish

Job Description

RN Medical Reviewer III

BlueCross BlueShield of South Carolina

• Perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. • Document decisions using indicated protocol sets or clinical guidelines. • Provide support and review of medical claims and utilization practices. • 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.

Job Requirements

  • Associates in a job-related field
  • Graduate of Accredited School of Nursing
  • 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical.
  • Working knowledge of managed care and various forms of health care 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 software.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgment skills.
  • Demonstrated customer service and organizational skills.
  • Ability to persuade, negotiate, or influence others.
  • Analytical or critical thinking skills.
  • Ability to handle confidential or sensitive information with discretion.
  • 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), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.

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

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