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RN 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 for claims or operations .
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 coding procedures, with a strong focus on clinical guidelines and medical necessity. Proficient in educating staff and managing quality control activities while maintaining confidentiality and discretion.
Highest-signal resume keywords
Active RN LicensureClinical ExperienceMedical Claim ReviewMicrosoft Office ProficiencyAnalytical Skills
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 Claim ReviewPayment DeterminationCoding ProceduresClinical GuidelinesMedical Necessity AssessmentQuality AssuranceUtilization ReviewCritical ThinkingJudgment SkillsCustomer Service
Soft Skills
Organizational SkillsOral CommunicationWritten CommunicationIndependencePrioritization
Tools & Technologies
Word Processing SoftwareMicrosoft OfficeWindows-Based Programs
Certifications & Qualifications
Active RN LicensureAssociate Degree in Nursing
Industry Keywords
Medicare ExperienceClaims ExperienceClinical ExperienceHealthcare ComplianceMedical Terminology
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 for claims or operations
- Make payment determinations using clinical medical information and established criteria, protocol sets, or clinical guidelines
- Determine medical necessity, appropriateness, reasonableness, coverage, and reimbursement
- Monitor process timeliness in accordance with 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 the state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
- Associate degree in Nursing OR graduation from 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 for working from home
- Preferred: five years of varied RN nursing experience including Medical/Utilization Review, Quality Assurance, Emergency, Critical Care, or Medical/Surgical experience
- Medicare or claims experience is a plus
- Preferred: ability to use multiple Windows-based programs simultaneously
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
- Diverse and inclusive workplace with opportunities to develop skills and advance careers
- Reasonable accommodations for individuals with disabilities, pregnancy-related conditions, or sincerely held religious beliefs