RN Medical Reviewer III

For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state. We are the largest insurance company in South Carolina. We are also the only one that has an A+ Superior A.M. Best rating. We are one of the nation's leading government contract administrators. We operate one of the most sophisticated data processing centers in the Southeast and have a diverse family of subsidiary companies. Our full-time employees enjoy benefits like a 401(k) retirement savings plan with company match, subsidized health plans, free vision coverage, life insurance, paid annual leave and holidays, wellness programs and education assistance. If you are a full-time employee in the National Guard or reserves, we will cover the difference in your pay if you are called to active duty. BlueCross has a dedicated corporate culture of community support. Our employees are some of the most giving in the country. They support dozens of nonprofit organizations every year. If you're ready to join a diverse company with secure, community roots and an innovative future, apply for a position now! BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

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 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.

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.