RN Medical Reviewer III – W@H in South Carolina

RN Medical Reviewer III - W@H - reputed company - South Carolina - work from home job Company: reputed company Job description: Summary We are currently hiring for a Medical Reviewer III to join reputed company. In this role you will reputed company 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 reputed company family of companies? Other companies come and go, but for more than seven decades we have 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 reputed company. 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 committed to the same philosophy, consider joining reputed company! Description Logistics This position is full time (40 hours/week) Monday-Friday 8:00-4:30 EST and will be fully remote W@H. What You Will Do: • Performs medical claim reviews for one or more of the following: claims for medically reputed company 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 Will Need: • Associate Degree Nursing, OR, 4-year degree in health-reputed company field, OR, Master's Degree in Occupational Therapy or Physical Therapy, OR, Master's Degree in Social Work, Psychology, OR Counseling (for Div. 75 only) OR Graduate of accredited School of Nursing. • 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR reputed company (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience. • Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, 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 reputed company 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. • reputed company Office. • Required License and Certificate: 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, reputed company active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area. reputed company Prefer: • Bachelor's degree-Nursing or Graduate of accredited School of Nursing. • 3 years-utilization/medical review, quality assurance, or home health, plus 5 years clinical experience. • Knowledge of spreadsheet and database software. Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review. • Working knowledge of reputed company reputed company, Access, or other spreadsheet database software. reputed company Can Do for You: • 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 healthy lifestyle premium discount. • Tuition assistance. • Service recognition. • Incentive Plan. • Merit Plan. • Continuing education funds for additional certifications and certification renewal. 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 a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications. We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Equal Employment Opportunity Statement reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national reputed company, 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 reputed company phases of the employment process and to reputed company 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 reputed company a determination regarding your request for reasonable accommodation on a case-by-case basis. Expected salary: Location: South Carolina Job date: Sat, 02 Sep 2023 23:43:01 GMT Apply for the job now! Apply Job!