About

Summary Join a great and supportive team whose focus is Medicare Part B claims. You will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. You will document decisions using indicated protocol sets or clinical guidelines. You will provide support and review of medical claims and utilization practices. Description Logistics: Palmetto GBA- one of BlueCross BlueShield's South Carolina subsidiary companies. Work hours during training 8:00 am to 5:00 pm Monday through Friday. Training: 2-3 weeks, required to be on camera during remote training, hours 8:00 AM - 5:00 PM EST, You must have high-speed (non-satellite) internet service and a private home office in South Carolina, Tennessee, Alabama and North Carolina, Georgia. What You’ll Do: 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, 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. Monitors process’s timeliness in accordance with contractor standards. 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. To Qualify for This Position, You’ll Need: 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), Required Education: Associates in a job-related field OR graduate of Accredited School of Nursing. Required Work Experience: Two years of clinical nursing 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 Tools: Microsoft Office. We Prefer That You Have: Work Experience: Five years nursing experience in one or a combination of: Medical Review, Utilization Review, Quality Assurance, ER, and/or Critical Care. Software and Tools: Ability to navigate between multiple windows-based programs. Experience with spreadsheet, email, and word processing programs. Preferred skills: Knowledge of CMS guidelines and Medicare Part B What We Can Do for You : Our comprehensive benefits package includes: 401(k) retirement savings plan with company match Subsidized health plans and free vision coverage Life insurance Paid annual leave — the longer you work here, the more you earn Nine paid holidays On-site cafeterias and fitness centers in major 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 mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 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. Here's more information. Some states have required notifications. Here's more information. If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit. Welcome Here’s Your Smart Career Move Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. Join Us If you're ready to join in a diverse company with secure, community roots and an innovative future, apply for a position now!