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.

• Work hours during training 8:00 am to 5:00 pm Monday through Friday.

• Training: 2-3 weeks, required to be on camera during remote training, hours 8:00 AM - 5:00 PM EST,

• You must have high-speed (non-satellite) internet service and a private home office in South Carolina, Tennessee, Alabama and North Carolina, Georgia.

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:

• Associate Degree - Nursing, OR ​Graduate of Accredited School of Nursing

• An active, unrestricted RN license 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)

• Two years clinical experience as an RN.

• Microsoft Office.

We Prefer That You Have:

• Two years Medical/Utilization Review or Public Health experience strongly preferred.

• Bachelor's degree - Nursing (BSN)

• Medicare Part B experience.

• Medical/Surgical or Emergency Room experience.

What We Can Do for You

Our comprehensive benefits package includes:

• 401(k) retirement savings plan with company match

• Subsidized health plans and free vision coverage

• Life insurance

• Paid annual leave — the longer you work here, the more you earn

• Nine paid holidays

• On-site cafeterias and fitness centers in major locations

• Wellness programs and a healthy lifestyle premium discount

• Tuition assistance

• Service recognition

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 disabilities and 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.com or 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 more information.

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