Job Description

Identifies, 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

• RN 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

What You’ll Get

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community 

• Work-life balance, flexibility, and the autonomy to do great work  

• Medical, dental, and vision coverage along with numerous health and wellness programs  

• Parental leave and support plus adoption and surrogacy assistance  

• Career development programs and tuition reimbursement for continued education  

• 401k match including an annual company contribution  

• Learn more  

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$73,698.00 - $117,917.00

Skills