Summary
 

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.

Description
 

Logistics:

CGS Administrators https://www.cgsadmin.com – one of BlueCross BlueShield’s South Carolina subsidiary companies.

Location:

• Preferred candidate will live in Nashville, TN area. For those living within 30 miles of our Nashville, TN office, the position would be hybrid (in-office and work from home). Highly qualified candidates outside the Nashville area will also be considered. For those living outside Nashville area, the position will be fully remote.

• This position is full-time (40-hours/week) Monday-Friday in a typical home office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00 AM-5:00 PM Monday through Friday. It may be necessary, given the business need, to occasionally work beyond these hours.

What You'll Do:

• Perform 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. Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement. Monitor process’s timeliness in accordance with contractor standards. Document medical rationale to justify payment or denial of services and/or supplies. Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participate in quality control activities supporting corporate and team-based objectives. Provide guidance, direction, and input as needed to LPN team members. Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assist with special projects and specialty duties and responsibilities as assigned by management.

To Qualify for This Position, You'll Need:

• Education: Associate degree - Nursing OR Graduate of an accredited School of Nursing.
• Work Experience: Two years of clinical experience as an RN.
• 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.
• Software and Tools: Microsoft Office.
• License: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

What We Prefer You Have:

• Work Experience: Five years of varied RN nursing experience to include:  Medical/Utilization Review, Emergency, Critical Care and/or Rehabilitation, strongly preferred. Medicare o