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Medical Reviewer II
BlueCross BlueShield of South Carolina. Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claim reviews, payment determinations, and clinical guidelines while effectively educating staff and ensuring compliance with established protocols. Proficient in utilizing analytical skills to assess medical necessity and manage documentation for claims processing.
Highest-signal resume keywords
Active RN LicensureMedical Claim ReviewClinical ExperienceAnalytical SkillsMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity DeterminationCoding ProceduresQuality AssuranceUtilization ReviewClinical GuidelinesPayment DeterminationDocumentation SkillsCritical Care ExperienceEmergency Nursing ExperienceMedical/Surgical Experience
Soft Skills
Good Judgment SkillsOrganizational SkillsOral Communication SkillsWritten Communication SkillsCustomer Service Skills
Tools & Technologies
Word Processing SoftwareWindows-Based ProgramsHigh-Speed InternetPrivate Home Office
Certifications & Qualifications
Active Compact Multistate RN LicenseAssociate Degree in Nursing
Industry Keywords
Medicare ExperienceClaims ExperiencePreauthorization RequestsFraud ReferralsReconsiderations
About the role
Key responsibilities & impact- Perform medical claim reviews for medically complex services, preauthorization/predetermination requests, appeals or reconsiderations, potential fraud and/or abuse referrals, and correct coding
- Make payment determinations based on clinical medical information and established criteria, protocols, or clinical guidelines
- Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement
- Monitor process timeliness according to contractor standards
- Document medical rationale supporting payment or denial of services and supplies
- Educate internal and external staff on medical reviews, medical terminology, coverage determinations, and coding procedures
- Participate in quality control activities supporting corporate and team objectives
- Provide guidance, direction, and input to LPN team members
- Educate non-medical staff through discussions, team meetings, classroom participation, and feedback
- Assist with special projects and specialty duties assigned by management
Requirements
What you’ll need- Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Associate degree - Nursing OR graduate of an accredited School of Nursing
- Two years of clinical experience as an RN
- 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
- Microsoft Office proficiency
- High-speed non-satellite internet service
- Private home office
- Ability to work Monday-Friday, 8-hour shifts during 8:00 AM-5:00 PM ET business hours
- Five years of varied RN nursing experience including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience strongly preferred
- Medicare or claims experience is a plus
- Ability to use multiple Windows-based programs simultaneously is preferred
Benefits
Comp & perks- 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
- Six-week paid training class
- Diverse and inclusive workplace with opportunities to develop skills and advance careers