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LPN Medical Reviewer I (remote after ~6 months) - PGBA

Description
 

Logistics

 

What You Will Do:

  • May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination.
  • Monitors process's timeliness in accordance with contractor standards.
  • Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
  • Utilizes allocated resources to back up review determination.
  • Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
  • May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
  • Performs screenings/assessments and determines risk via telephone.
  • Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
  • Provides education to members and their families/caregivers.
  • Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.
  • Conducts research necessary to make thorough/accurate basis for each determination made.
  • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
  • Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
  • Participates in quality control activities in support of the corporate and team-based objectives.
  • Participates in all required training.

 

To Qualify for This Position, You Will Need:

  • Required Licenses and Certificates: Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire.
  • Required Education: Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing. Or Bachelor's degree - Social Work.
  • Required Experience: 2 years clinical experience.
  • Required Skills and Abilities: Working knowledge of word processing software. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to remain in a stationary position and operate a computer.
  • Required Software and Tools: Microsoft Office.

 

What We Prefer You Have:

  • Active, unrestricted LPN/RN compact multistate license strongly preferred.
  • Five years nursing experience in varied nursing settings including medical/surgical or utilization review.
  • Ability to work with multiple windows-based programs simultaneously.
  • Intermediate spreadsheet, word processing and outlook experience.
  • Coding experience.

 

What We 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.

 

 

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 individuals with disabilitiesand 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.comor 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 moreinformation.

 

Some states have required notifications.

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