Reviewer III, Medical

About the position 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. Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Create and analyze reports to support operations. Ensure the correctness of analysis and report findings concisely to senior management. Directly responsible for data accuracy as financial and operational decisions are made based on the data provided. Logistics: CGS (cgsadmin.com) Location: This position is full-time (40-hours/week) Monday-Friday and can be worked remotely. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. Responsibilities • Performs 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, and correct coding for claims/operations. • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. • Documents medical rationale to justify payment or denial of services and/or supplies. • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. • Participates in quality control activities in support of the corporate and team-based objectives. • Provides 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. Requirements • Associate's 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 to include home health, rehabilitation, and/or broad medical surgical experience. • Knowledge of specific criteria/protocol sets and the use of the same. • 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. • Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. Nice-to-haves • Bachelor's degree-Nursing or Graduate of accredited School of Nursing. • 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical experience. • Knowledge of spreadsheet and database software. • Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review. • Working knowledge of Microsoft Excel, Access, or other spreadsheet database software. Benefits • 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 Apply tot his job