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!
We are excited to announce an opportunity for an RN Medical Reviewer II to join our Palmetto GBA Medical Review team.
In this position, you will use your clinical expertise to perform medical reviews, apply established clinical guidelines and protocol sets, and help ensure accurate, timely coverage and payment determinations.
You will also share your knowledge with others by educating internal and external staff and supporting our team's quality goals.
Ideal candidates will bring strong clinical experience, sound judgment, excellent written communication, and a genuine commitment to delivering high-quality work.
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 is a full-time, salaried position, Monday–Friday, in a typical home office environment.
You will work an 8-hour shift scheduled during our normal business hours of 8:00 AM–5:00 PM ET. It may be necessary, given the business need, to occasionally work additional hours. This position is Work at Home.
You must have high-speed (non-satellite) internet service and a private home office to work from home.
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, 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.
Monitors process timeliness in accordance with contractor standards.
Documents medical rationale to justify payment or denial of services and/or supplies.
Educates internal and 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 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's degree in a job-related field
Degree Equivalency: Graduate of…