RN Medical Reviewer III (W@H South Carolina)

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Overview

BlueCross BlueShield of South Carolina is seeking an RN Medical Reviewer III to join their team. This role involves performing medical reviews using clinical information provided by physicians and established criteria. The position offers a great opportunity for candidates interested in working in a dynamic environment with a focus on healthcare quality and analytics.

Job Position and Responsibilities

As an RN Medical Reviewer III, your primary responsibilities will include:

• Performing reviews of medical claims, such as claims for complex services and those needing preauthorization.
• Documenting decisions based on clinical guidelines and established protocols to support payment determinations.
• Providing education to both internal and external staff about medical reviews and coverage determinations.
• Participating in quality control efforts and collaborating with team members to support corporate objectives.
• Assisting with special projects and assuming additional duties as assigned by management.

This position is full-time, working 40 hours a week, Monday through Friday with an 8-hour shift scheduled between 6:00 AM and 5:00 PM EST. The role is also fully remote, although candidates may occasionally need to report on-site for training or meetings.

Required Skills and Qualifications

To qualify for this position, candidates must possess the following:

• A graduate degree from an accredited nursing school or an Associate's in a related field.
• At least 2 years of clinical experience plus 1 year of utilization/medical review, or at least 3 years of clinical experience.
• A strong understanding of managed care and healthcare delivery systems, alongside substantial clinical experience in areas such as home health and rehabilitation.
• Working knowledge of medical coding and necessary criteria/protocols.
• Proficiency in Microsoft Office, as well as the ability to work independently, prioritize, and make sound decisions.
• Excellent oral and written communication skills.

Candidates will also need an active unrestricted RN license from the United States. This can be either in the state of hire or as provided by the Nurse Licensure Compact (NLC).

Preferred Qualifications

While the basic requirements are essential to the application process, the following preferred qualifications will give candidates an advantage:

• A Bachelor's degree in nursing or graduation from an accredited nursing school.
• 3 years of utilization/medical review experience, along with 5 years of clinical experience.
• Proficient writing skills and keen attention to detail.
• Knowledge of Medicare regulations and system processing procedures related to medical reviews.

Compensation and Benefits

Although specific salary details were not disclosed in the job posting, interested candidates can expect the following benefits:

• 401(k) retirement savings plan with a company match.
• Health plans with subsidies and free vision coverage.
• Paid annual leave, increasing with tenure, and nine paid holidays each year.
• Access to on-site cafeterias and fitness centers in major locations.
• Wellness programs promoting healthy lifestyle choices.
• Tuition assistance for continued education and certification renewals.
• A merit plan, incentive plan, and continuing education funds.

These perks are indicative of a supportive work environment that values the well-being and professional development of its employees.

Application Process

Candidates interested in the RN Medical Reviewer III position are encouraged to apply promptly. The recruitment team will review resumes to ensure every candidate meets the qualifications outlined. This might involve a brief phone interview or email to confirm resume details and salary requirements.

After initial screening, candidates who meet the criteria will be invited for interviews. Preference will be shown to those who exhibit the preferred qualifications listed in the job description. BlueCross BlueShield of South Carolina engages in E-Verify and upholds principles of equal employment opportunity, providing non-discriminatory practices throughout the hiring process. Special accommodations are available during the application process for individuals with disabilities.

Final Thoughts

Working with BlueCross BlueShield of South Carolina as an RN Medical Reviewer III means joining a team committed to excellence in healthcare services. The position not only provides a chance to contribute meaningfully to the healthcare system but also offers the flexibility of remote work in a supportive and evolving environment. Job seekers looking for a role that combines clinical expertise with analytical skills may find this opportunity to be a perfect fit.

This job offer was originally published on himalayas.app