Job Description

Medical Review Specialist

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.

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

Location: This position is full-time (40 hours/week) Monday through Friday in a typical office environment. This role is remote position for South Carolina, Georgia, North Carolina or Alabama.

What You'll Do:

• Perform 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. Make reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determine medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process's timeliness in accordance with contractor standards. Document medical rationale to justify payment or denial of services and/or supplies.
• Educate internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities in support of the corporate and team-based objectives. Provide 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 Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• 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 Other Tools: Microsoft Office.

Our comprehensive benefits package includes the following:

• 401(k) retirement savings plan with company match
• Subsidized health plans, dental and vision coverage
• Life insurance
• Paid Time Off (PTO)
• Nine paid holidays
• On-site cafeterias and fitness centers in significant locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service Recognition

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.

Management will conduct interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

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.

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