Medical Claims Reviewer ( RN Administrative role)

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Located in Columbia, SC

Salary: $62,400- 77,000 per year BOE

A local insurance agency is urgently hiring Manage Care Coordinators to support their expanding customer base. 

Pay: $62,400- 77,000 annually

This is a hybrid role. Applicants must be local to Columbia, SC and available to work on site at least 2 days per week. 

• Applicants must have clinical experience in Nursing and a valid SC Registered Nursing License 

Job Duties:

• Reviews and evaluates medical or behavioral eligibility regarding benefits and clinical criteria by applying clinical expertise, administrative policies, and established clinical criteria to service requests or provides health management program interventions.
• Utilizes clinical proficiency, claims knowledge/analysis, and comprehensive knowledge of healthcare continuum to assess, plan, implement, coordinate, monitor, and evaluate medical necessity, options, and services required to support members in managing their health, chronic illness, or acute illness.
• Utilizes available resources to promote quality, cost effective outcomes.
• Provides active case management, assesses service needs, develops and coordinates action plans in cooperation with members, monitors services and implements plans, to include member goals.
• Evaluates outcomes of plans, eligibility, level of benefits, place of service, length of stay, and medical necessity regarding requested services and benefit exceptions.
• Ensures accurate documentation of clinical information to support and determine medical necessity criteria and contract benefits.
• Provides telephonic support for members with chronic conditions, high risk pregnancy or other at risk conditions thatconsist of: intensive assessment/evaluation of condition, at risk education based on members’ identified needs, provides member-centered coaching utilizing motivational interviewing techniques in combination with reflective listening and readiness to change assessment to elicit behavior change and increase member program engagement. 20% Performs medical or behavioral review/authorization process.
•  Ensures coverage for appropriate services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determinations. Identifies and makes referrals to appropriate staff (Medical Director, Case Manager, Preventive Services, Subrogation, Quality of care Referrals, etc.).
• Participates in data collection/input into system for clinical information flow and proper claims adjudication.
• Demonstrates compliance with all applicable legislation and guidelines for all regulatory bodies, which may include but is not limited to ERISA, NCQA, URAC, DOI (State), and DOL (Federal).
• Participates in direct intervention/patient education with members and providers regarding health care delivery system, utilization on networks and benefit plans.
•  May identify, initiate, and participate in on-site reviews.
• Serves as member advocate through continued communication and education.
• Promotes enrollment in care management programs and/or health and disease management programs.
• Maintains current knowledge of contracts and network status of all service providers and applies appropriately.
• Assists with claims information, discussion, and/or resolution and refers to appropriate internal support areas to ensure proper processing of authorized or unauthorized services.
• Provides appropriate communications (written, telephone) regarding requested services to both health care providers and members.

Qualifications:

• Valid LPN or RN South Carolina Nursing License 
• Associates of Nursing Science Degree (ASN) required, Bachelor of Nursing Science Degree (BSN) preferred
• 2 years of clinical nursing experience required 4 years preferred 
• 2 years of claims management or case reviewing experience preferred but not required 
• Ability to type 30+ WPM 
• Ability to meet background and drug testing requirements 

Benefits of Working with Express: 

• Health, Vision, Dental, Term-life, and Short-Term Disability insurance available
• Paid Vacation time 
• Paid Holidays 
• Weekly Pay

If interested, please call us for an interview at 803-788-8721 and send resume to Caroline.hughes@expresspros.com

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