RN Medical Reviewer II - Palmetto GBA

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

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 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 the state of hire, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).