RN Medical Reviewer II

About the role

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's South Carolina subsidiary companies. Location: This is a full-time, remote work-from-home position . All training will be conducted virtually. Candidates must have reliable high-speed internet service (satellite internet is not permitted) and a private home office or dedicated workspace. The work schedule consists of an 8-hour shift, Monday through Friday, between the hours of 6:00 a.m. and 7:00 p.m. ET . Work schedules will be assigned within these operating hours

Responsibilities

• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• 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).
• We Prefer That You Have The Following:
• At least 5 years of bedside nursing experience .
• Clinical experience in Hospice, Home Health, or ICU environments.
• Prior experience with medical claims review and/or utilization review.
• 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 our recruiter to verify resume specifics and salary requirements.
• Equal Employment Opportunity Statement

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