Registered Nurse Clinical Reviewer performing medical - legal reviews and appeals at Greenlife Healthcare Staffing. Hybrid role requiring both remote and office - based tasks in New York.
About the role
- Medical Reviewer conducting medical claims reviews for BlueCross BlueShield of South Carolina. Working onsite initially then transitioning to remote after training period.
Responsibilities
- 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
- 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
Requirements
- Associate's in a job related field
- Graduate of Accredited School of Nursing
- 2 years clinical experience
- 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
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Benefits
- Subsidized health plans
- Dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
Performs medical reviews and utilization management of facility benefits at BlueCross BlueShield. Responsible for documentation and support of medical claims and utilization practices.
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