RN Medical Reviewer II - Palmetto GBA

Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

Palmetto GBA is a trusted BlueCross BlueShield subsidiary company specializing in government healthcare programs. We work with CMS (Centers for Medicare & Medicaid Services) to ensure quality healthcare services and accurate claims processing for Medicare beneficiaries across the nation.

After training - Choose your core hours (7 AM-3:30 PM est, 8 AM-4:30 PM est, or 9 AM-5:30 PM est)

• 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.

Required Education:

• Associate Degree - Nursing, OR

• Graduate of an accredited School of Nursing

Required Work Experience:

• Twoyears of clinical experience.

Preferred Work Experience:

• Previous medical review or utilization review 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 training: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Equal Employment Opportunity Statement

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 individuals with disabilitiesand protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.comor call 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.

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

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