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Job Discription
Internal Reference Number: R1015639
Summary Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.
If you have demonstrated excellent communication skills in the workplace and are passionate about working with a great health care delivery team, we welcome you to apply!Description
May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process’s timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination.
Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone.
Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
Participates in quality control activities in support of the corporate and team-based objectives. Participates in all required training.
Logistics:
This role has the flexibility to work in either a hybrid (3 days per week), or on-site position based upon management approval, once the training period has been completed.
Required Education:
Bachelor’s degree OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
Required Work Experience:
Two years clinical experience.
Preferred Work Experience:
Medicare claims experience.
Post-service utilization management medical necessity review.
Required Skills and Abilities:
Working knowledge of word processing software.
Good judgment skills.
Demonstrated customer service and organizational skills.
Demonstrated proficiency in spelling, punctuation, and grammar skills.Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Ability to remain in a stationary position and operate a computer.
Preferred Skills and Abilities:
Working knowledge of spreadsheet and database software.
Demonstrated oral and written communication skills.
Ability to persuade, negotiate, or influence others.
Required Software and Tools:
Microsoft Office, to include Excel, Word and PowerPoint.
Required Licenses and Certificates:
Active, unrestricted LPN/LVN or RN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC)
Work Environment:
Typical office environment some travel between office buildings.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
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 minorities, females, disabled individuals and 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 physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
