Vacancy caducado!
Additional Locations:Full Time Remote - Alabama, Full Time Remote - Alabama, Full Time Remote - Arizona, Full Time Remote - Arkansas, Full Time Remote - Florida, Full Time Remote - Georgia, Full Time Remote - Idaho, Full Time Remote - Indiana, Full Time Remote - Iowa, Full Time Remote - Kansas, Full Time Remote - Kentucky, Full Time Remote - Louisiana, Full Time Remote - Maryland, Full Time Remote - Michigan, Full Time Remote - Mississippi, Full Time Remote - Missouri, Full Time Remote - Ohio, Full Time Remote - Oklahoma, Full Time Remote - Pennsylvania, Full Time Remote - South Carolina, Full Time Remote - South Dakota, Full Time Remote - Tennessee, Full Time Remote - Texas, Full Time Remote - Utah, Full Time Remote - Virginia {+ 1 more}Job DescriptionIdentifies, analyzes, and determines medical necessity, pre-existing conditions, benefit eligibility and/or individual consideration reimbursement allowances for novel and complex medical management related claims, using varied and broad clinical expertise. The Medical Review Analyst acts as a member advocate to promote and coordinate the delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits.What You'll Do
Determines, medical necessity, benefit eligibility and/or appropriate reimbursement allowances for complex claims and/or products by using clinical experience, medical literature, medical records, certificate guidelines, medical policy and several complex and varied computer application software systems.
Ensures that review and determinations meet all requirements per line of business by Regulatory and Accrediting bodies (e.g., federal, state and BCBSA etc.).
Identifies, documents, and escalates system and process problems. Through analysis, determines root cause and recommends possible solutions. Defines, communicates and follows up as appropriate on the root causes of errors to others.
Reviews physician-submitted and member-submitted claims for specified services, utilizing professional knowledge and developed criteria, to determine the medical necessity of the treatment. Refers cases that do not meet criteria to the Medical Director with appropriate clinical analysis and summaries. Issues denials according to department protocols. Documents outcome of reviews.
Maintains confidentiality of all PHI in compliance with state and federal laws.
Recognizes, documents, and reports inappropriate billing patterns or utilization trends of professional and institutional providers to appropriate business owner. Identifies situations in which claims filing/coding guidelines are not being followed by providers; documents examples for referral to Network Management and/or Special Investigations for appropriate action.
Communicates with members and providers to obtain additional information. Informs members, providers, and internal customers of claims status and determinations. Documents the required clinical information, source and rationale (referencing the appropriate internal and external resources) for decision-making in the appropriate medical management tools.
Performs post adjudication review of claims related to coding, billing and reimbursement. (FEP and Senior Market, Medicare HMO/PPO)
Reviews claims for Individual Business for possible misrepresentation as needed. Gathers information and prepares documentation for internal review. Takes appropriate action based on internal guidelines.
What You'll Bring (Hiring Requirements)
RN, PA or NP with a minimum of 3 years previous clinical experience preferably in a variety of clinical settings
LPN with a minimum of 5 years previous clinical nursing experience preferably in a variety of clinical settings
Must hold and maintain a valid North Carolina clinical license
Nice to Have (Preferred Skills)
Experience in reviewing healthcare claims for fraud, waste and/or abuse situations.
It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.Blue Cross NC is a fully taxed, not-for-profit North Carolina company with major operations centers in Durham and Winston-Salem. We employ more than 5,000 people who are passionate about health care, and we serve more than 4.3 million members.Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.E-VerifyOur company uses E-Verify to confirm the employment eligibility of all newly hired employees. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.Third Party Staffing AgenciesBlue Cross NC does not accept unsolicited resumes from any source other than directly from candidates. For the protection of all parties involved in the recruiting process, resumes will only be accepted from recruiters/agencies if a signed agreement is in place at the inception of the recruiting effort and authorized for a specific position. Unsolicited resumes sent to Blue Cross NC from recruiters/agencies do not constitute any type of relationship between the recruiter/agency and Blue Cross NC and do not obligate Blue Cross NC to pay fees if we hire from those resumes.
Vacancy caducado!