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RN Medical Reviewer III
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, clinical guidelines, and coding procedures while effectively educating staff and ensuring compliance with healthcare regulations. Possesses strong analytical skills and the ability to make sound decisions regarding medical necessity and coverage determinations.
Highest-signal resume keywords
Active RN LicensureMedical Claim ReviewClinical Guidelines KnowledgeUtilization Review ExperienceCustomer Service 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 Necessity DeterminationClinical ReviewQuality AssuranceCoding ProceduresAnalytical Skills
Soft Skills
Effective CommunicationDecision-MakingOrganizational SkillsJudgment SkillsPersuasion Skills
Tools & Technologies
Microsoft OfficeWord Processing SoftwareSpreadsheet SoftwareDatabase Software
Certifications & Qualifications
Active RN LicensureCompact Multistate RN License
Industry Keywords
Managed CareHome HealthMedical Review ProcessingMedicare RegulationsHealthcare Delivery Systems
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 charge payment determinations using clinical/medical information and established criteria, protocol sets, or clinical guidelines
- Determine medical necessity, appropriateness, reasonableness, and necessity for coverage and reimbursement
- Monitor process timeliness according to contractor standards
- Document medical rationale supporting payment or denial of services and/or 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
- Work full-time, 40 hours per week, Monday-Friday, on an 8-hour shift between 6:00 a.m. and 5:00 p.m.
Requirements
What you’ll need- Associates in a job-related field
- Graduate of Accredited School of Nursing
- 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical
- For Palmetto GBA (Co. 033) only: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience
- Working knowledge of managed care and various forms of health care delivery systems
- Strong clinical experience including home health, rehabilitation, and/or broad medical surgical experience
- Knowledge of specific criteria/protocol sets and their use
- 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
- Ability to persuade, negotiate, or influence others
- Analytical or critical thinking skills
- Ability to handle confidential or sensitive information with discretion
- Microsoft Office proficiency
- Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license under the Nurse Licensure Compact, OR current active, unrestricted U.S. and state-of-hire specialty licensure/certification as required by the hiring division/area
- Preferred: Well-rounded adult clinical experience, such as medical-surgical, ER, or critical care
- Preferred: Knowledge of spreadsheet and database software
- Preferred: Knowledge of Medicare and/or related regulations, policies, instructions, provisions, home health, and/or medical review processing procedures
- Preferred: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software
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
- Opportunity to develop skills, advance careers, and contribute to company growth
- Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs