- 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.
- Evaluates claim submissions/documentation for completeness and validity to determine payment/denial according to member's plan benefits and department claims processing policies and procedures. Create workflow balance to ensure prepayment claims are reviewed timely and accurately.
- 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 Medical 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.
- Performs other duties as assigned adhering to all program, agency, State and other related policies, procedures, privacy, and timeliness standards.
- Participates in SCDHHS initiatives and projects as needed to achieve goals and improve processes.
- Meets professional development goals as assigned by management. Participates in cross training opportunities. Coordinates the creation of individual professional development plan with manager. Monitors progress toward continuing professional development.
- Health, Dental, Vision, Long Term Disability, and Life Insurance for Employee, Spouse, and Children
- 15 days annual (vacation) leave per year
- 15 days sick leave per year
- 13 paid holidays
- State Retirement Plan and Deferred Compensation Programs
- Sitting or standing for long periods of time.
- Degree/license/certification/s in a relevant healthcare discipline.
- Knowledge of Medicare and/or Medicaid regulations.
- Medical record abstracting skills.
- Knowledge of the organization of medical records, medical terminology, and disease process.
- Strong clinical assessment and critical thinking skills.
- Excellent verbal and written communication skills.
- Ability to work in a team environment.
- Flexibility and strong organizational skills.
- Proficiency in Microsoft Office and internet/web navigation.
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nurse practitioner, non-institutional #586
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State of South Carolina Columbia, SC , USA, United StatesJob Responsibilities · This position is located at Department of Mental Health/Columbia Area Mental Health Center-Medical Services, CAMHC #586. · Under general supervision, within one or more assigned locations, provides clinical services within the scope allowed by the collabora ...
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State of South Carolina Columbia, SC, United StatesJob Responsibilities · * This position is a re-post. Previous applicants do not need to re-apply.* · The Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians. · This position is located in Community Long Term Care, Anderson ...
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State of South Carolina Columbia, United StatesJob Responsibilities · This position is located at Department of Mental Health-Columbia Area Mental Health Center, Adult Clinic Services, CAMHC #384. · Under general supervision, provide primary monitoring of the Adult Clinic Services Medication line, accepting calls and voice ma ...
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Travel Nurse RN
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Tact Staff Columbia, SC, United StatesTact Staff is seeking a travel nurse RN Med Surg / Telemetry for a travel nursing job in Columbia, South Carolina. · Job Description & Requirements · Specialty: Med Surg / Telemetry · Discipline: RN · Start Date: ASAP · Duration: 13 weeks · 36 hours per week · Shift: 12 hours · E ...
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The Curare Group Columbia, United StatesVascular Surgery opportunity with a large non-profit hospital system in South Carolina. Seeking a Board Certified/Board Eligible Vascular Surgeon to join an established and growing practice in the area. This position offers a set schedule with dedicated call, OR, and clinic days. ...
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RCM HealthCare Travel Columbia, SC, United StatesRCM HealthCare Travel is seeking a travel nurse RN PCU - Progressive Care Unit for a travel nursing job in Columbia, South Carolina. · Job Description & Requirements · Specialty: PCU - Progressive Care Unit · Discipline: RN · Start Date: 06/03/2024 · Duration: 13 weeks · 36 hours ...
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Travel Nurse RN
1 week ago
Tact Staff Columbia, United StatesJob Description · Tact Staff is seeking a travel nurse RN Med Surg / Telemetry for a travel nursing job in Columbia, South Carolina. · Job Description & RequirementsSpecialty: Med Surg / Telemetry · Discipline: RN · Start Date: ASAP · Duration: 13 weeks · 36 hours per week · Shif ...
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Registered Nurse
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Prisma Health Columbia, SC, United StatesJob Id · R · Inspire health. Serve with compassion. Be the difference. · Job Summary · The Nurse-Resident job has the responsibility of attending all quality and core curriculum classes, actively participating in professional development workshops and peer support groups, and su ...
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The ECPI University Columbia, SC, United StatesTeach in five-week intervals in small classes. Share valuable industry experience in a nurturing environment Qualifications Qualifications Education/ Credentials. Bachelors degree in Nursing from a regionally accredited educational institution requir Faculty, Obstetrics, Pediatri ...
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Travel Nurse RN
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Travel Nurses, Inc. Columbia, SC, United StatesTravel Nurses, Inc. is seeking a travel nurse RN ED - Emergency Department for a travel nursing job in Columbia, South Carolina. · Job Description & Requirements · Specialty: ED - Emergency Department · Discipline: RN · Duration: 13 weeks · 36 hours per week · Shift: 12 hours, ni ...
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Travel Nurse RN
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Travel Nurses, Inc. Columbia, United StatesJob Description · Travel Nurses, Inc. is seeking a travel nurse RN Med Surg / Telemetry for a travel nursing job in Columbia, South Carolina. · Job Description & RequirementsSpecialty: Med Surg / Telemetry · Discipline: RN · Duration: 13 weeks · 36 hours per week · Shift: 12 hour ...
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Travel Nurse RN
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Travel Nurses, Inc. Columbia, United StatesJob Description · Travel Nurses, Inc. is seeking a travel nurse RN ED - Emergency Department for a travel nursing job in Columbia, South Carolina. · Job Description & RequirementsSpecialty: ED - Emergency Department · Discipline: RN · Duration: 13 weeks · 36 hours per week · Shif ...
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Travel Nurse RN
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Vibra Travels Columbia, United StatesJob Description · Vibra Travels is seeking a travel nurse RN ED - Emergency Department for a travel nursing job in Columbia, South Carolina. · Job Description & RequirementsSpecialty: ED - Emergency Department · Discipline: RN · Duration: 13 weeks · 36 hours per week · Shift: 12 ...
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Travel Nurse RN
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Travel Nurses, Inc. Columbia, United StatesJob Description · Travel Nurses, Inc. is seeking a travel nurse RN Med Surg / Telemetry for a travel nursing job in Columbia, South Carolina. · Job Description & RequirementsSpecialty: Med Surg / Telemetry · Discipline: RN · Duration: 13 weeks · 36 hours per week · Shift: 12 hour ...
registered nurse, non-institutional - Columbia, SC , USA, United States - State of South Carolina
Description
Job ResponsibilitiesThe Agency's mission is to be boldly innovative in improving the health and quality of life for South Carolinians.
This position is located in Bureau of Provider & Support Services, Richland County.
Are you the One? We are looking for a Registered Nurse, Non-Institutional who will serve as a Registered Nurse (RN) in the Office of Claims Resolution within the South Carolina Department of Health and Human Services Bureau of Provider and Support Services.
Primary responsibilities include providing review of claims with specific criteria that require medical coding, medical necessity review and determinations and treatment knowledge to successfully adjudicate within a set timeframe and collaborating with internal teams on provider education, process improvement and proactive communication to improve established metrics.
Work collaboratively with team members, Program Directors and Executive Leadership to support the needs of our providers and Medicaid members, delivering excellent customer service.
Performs medical record and claims review to ensure proper guidelines have been followed and medical necessity criteria has been met.
Identify and communicate reoccurring issues to reduce or eliminate claims review. Engage with appropriate team members to ensure processes are documented and updated. Ensures all documentation is clear, concise and easily understood, utilized by others and records are kept confidential.
Minimum three (3) years clinical experience in the medical field and a minimum of two (2) years healthcare experience that demonstrates expertise in conducting Utilization Reviews and/or Prior Authorization or related experience and graduation from an accredited school of nursing.
NECESSARY SPECIAL REQUIREMENT:
Must have current, active and non-restricted licensure by the State of South Carolina Board of Nursing as a Registered Nurse.
Additional Requirements:
Please complete the State application to include all current and previous work history and education.
A resume will not be accepted nor reviewed to determine if an applicant has met the qualifications for the position.
Supplemental questions are considered part of your official application for qualification purposes. All applicants must apply online. All correspondence from the Office of Human Resources will be through electronic mail.
The South Carolina Department of Health and Human Services is committed to providing equal employment opportunities to all applicants and does not discriminate on the basis of race, color, religion, sex (including pregnancy, childbirth or related medical conditions, including, but not limited, to lactation), national origin, age (40 or older), disability or genetic information.
