(RN) Medical Reviewer III

Logistics

This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H).

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.

• 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:

• Associates in a job-related field.

• Graduate of Accredited School of Nursing.

• Two-years clinical plus one year utilization/medical review, quality assurance, OR home health, OR three years clinical.

• FOR PALMETTO GBA (CO. 033) ONLY: two years clinical experience plus two years utilization/medical review, quality assurance, OR home health experience.

• 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.

• 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.

• Microsoft Office.

• 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.

We Prefer That You Have the Following:

• Bachelor's degree - Nursing OR Graduate of accredited School of Nursing.

• Three years-Utilization/Medical Review, Quality Assurance, OR Home Health, plus five years clinical experience.

• Must reside in South Carolina.

• Knowledge of spreadsheet and database software.

• Knowledge of Medicare and/or regulations/policies/instructions/provisions, Home Health, and/or system/processing procedures for Medical Review.

• Working knowledge of Microsoft Excel, Access, OR other spreadsheet database software.

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.

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 with a recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

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

Some states have required notifications. Here's more information.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.