Summary
 

We are currently hiring for a part-time salaried RN Medical Reviewer III to join our RRB (Railroad Retirement Benefits) team. In this role, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. You will also document decisions using indicated protocol sets or clinical guidelines and provide 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 for more than seven decades we’ve been part of the national landscape, 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 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!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics

• This position is part-time salaried position. General work hours are 8:00 am to Noon ET Monday through Friday (approximately 20 hours/week).
• Two weeks of full-time remote training from 8:00 am to 5:00 pm ET Monday through Friday.
• Position will be fully remote (W@H). To work from home, you must have high speed (non-satellite) internet service, the ability to install a VPN, and a private lockable home office.
• May be required to attend occasional meetings or trainings onsite in Augusta, GA.
• Preferred candidate will live in South Carolina or Georgia.

What You Will 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, 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.

To Qualify for This Position, You Will Need:

• License/Certification: 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.

• Education: Associate's in nursing or Graduate of Accredited School of Nursing.

• Experience: Two years clinical experience plus two years utilization/medical review, quality assurance, OR home health experience.

• Skills/Knowledge: 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.

• Software: Microsoft Office.

What We Prefer:

• Experience: Three years-utilization/medical review, or quality assurance PLUS five years clinical nursing experience. Palmetto GBA or BCBSSC medical review experience.

• Education: Bachelor's degree – Nursing OR Graduate of accredited School of Nursing.

• Skills/Knowledge: Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review.

• Software: Working knowledge of Microsoft Excel, Access, OR other spreadsheet database software.

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have access and opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Our comprehensive benefits package includes:

• 401(k) retirement savings plan with company match
• Fantastic 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

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualified candidates.

 

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

Some states have required notifications. Here's more information. 

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. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.