RN Medical Reviewer II - CGS

• →Documents the basis of the appeal or retrospective review in an accurate and timely manner and in accordance with applicable regulations or standards.
• →Performs thorough research of the substance of service appeals by both member and provider based on clinical documentation, contractual requirements, governing agencies, policies and procedures, while adhering to confidentiality regulations regarding protected health information.
• →Performs appeal and retrospective reviews demonstrating ability to define and determine precedence of pertinent issues in application of policies and procedures to clinical information and or application to benefit or policy provisions.
• →Performs special projects including reviews of clinical information to identify quality of care issues.

• Required Education: Associate's in a job related field
  • Degree Equivalency: Graduate of Accredited School of Nursing
• Required Work Experience:  2 years clinical experience 
• Required Skills and Abilities:
  • Working knowledge of word processing software.
  • Ability to work independently, prioritize effectively, and make sound decisions.
  • Good judgement skills.
  • Demonstrated customer service and organizational skills.
  • Demonstrated customer service, organizational, 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.
• Required License and Certificate: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). 

• Preferred Education: Bachelor's degree- Nursing.
• Preferred Work Experience: Work exposure to home health, hospice, case management, and/or utilization 
• Preferred Skills and Abilities: Computer literacy
• Preferred Software and Other Tools: Microsoft Office Suite

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

• 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.

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.

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