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
Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This 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.
Government Clearance: 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.
To Qualify for This Position, You'll Need the Following
- 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).