Must have current, active, and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
Phone/Skype Hire. Onsite from day 1 / REMOTE
Location: Columbia, SC / upto 80% remote
Duration: 12+ months
Rate: Open
The current position's focus and priority is the continued support of serving as a subject matter expert (SME), building knowledge that allows policy and process owners to make the best recommendations for Medicaid members and providers. A long-term plan includes participating and providing guidance in the administrative approach for the replacement Medicaid management system. It is necessary to build and sustain a strong clinical staff who understand medical coding, medical necessity review, treatment, and determinations.
Performs medical record and claims review to ensure proper guidelines have been followed and medical necessity criteria has been met.
Responsibilities
- Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care; determines if the medical record documentation supports the need for services.
- Maintain a thorough knowledge of medical coding and collaborates with team members to share knowledge and adjust processes, as necessary to comply with requirements. Reviews and maintains knowledge of relevant SC Medicaid Policies and Procedures impacting claims approval processes.
- Collaborate with other agency employees and external stakeholders, as necessary. Acts with proactive intent to improve claims related outcomes while considering input from team and making the best decisions to align with agency objectives and provider and member support.
Skills Needed
Current, active and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
2 years healthcare experience that demonstrates expertise in conducting Utilization Reviews and/or Prior Authorization or related experience
1 year experience working with IT developers/programmers in a payor environment
Knowledge of Medicare and/or Medicaid regulations.
Medical record abstracting skills.
Strong knowledge of formal business process documentation.
Ability to effectively communicate with executive management, line management, project management, and team members.
Strong clinical assessment and critical thinking skills.
Knowledge of the organization of medical records, medical terminology, and disease process.
Excellent verbal and written communication skills.
Flexibility and strong organizational skills.
Proficiency in Microsoft Office and internet/web navigation.
Ability to work in a team environment.
Required Education:
Bachelor of Science in Nursing (BSN) or Associate Degree in Nursing (ADN)
Required Certifications:
Must have current, active, and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
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