RN Medical Reviewer III

Medical Review III

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.

This is a fast-paced, highly collaborative remote role within the Data Strategy team. The ideal candidate thrives in a dynamic environment and is comfortable serving as both an independent contributor and an informal resource for peers.

The MR III functions as a subject matter expert in data strategy, providing guidance and serving as a knowledge resource for fellow nurses on the team.

This role requires ongoing, cross-functional coordination with Operations Analysts throughout the workday. Nurses identify and research providers; analysts execute the corresponding edits. The workflow is highly interdependent, with frequent email communication between teams.

Candidates must be comfortable navigating spreadsheets and interpreting reports. Understanding what the data means.

The Data Strategy nurses play a central role in generating and managing workload for the Medical Review (MRR) team. Accuracy, reliability, and attention to detail directly impact downstream operations.

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.

To qualify for this position, you'll need the following:

• Required Education: Associate's in a job related field
• Degree Equivalency: Graduate of Accredited School of Nursing.
• Required Licenses and Certificates: 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.
• Required Work Experience: 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.
• Required Skills and Abilities: 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.
• Required Software and Other Tools: Microsoft Office.

We prefer you have:

• Preferred Education: Bachelor's degree-Nursing or Graduate of accredited School of Nursing.
• Preferred Work Experience: 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical experience.
• Preferred Skills and Abilities: 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.
• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.

Our comprehensive benefits package includes the following:

• 401(k) retirement savings plan with company match
• Subsidized health plans, dental and vision coverage
• Life insurance
• Paid Time Off (PTO)
• Nine paid holidays
• On-site cafeterias and fitness centers in significant locations
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance
• Service Recognition

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email View email address on click.appcast.io or call View phone number on click.appcast.io with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.