Medical Reviewer I

Summary

We are currently hiring for a Medical Reviewer I to join BlueCross BlueShield of South Carolina. In this role as Medical Reviewer I, you will perform medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. You will also document decisions using indicated protocol sets or clinical guidelines and provide support and review of medical claims and utilization practices.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description

Logistics

This position is full time (40 hours/week) Monday-Friday and will be located at 4101 Percival Road, Columbia, S.C., 29229.

What You Will Do

• May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination.
• Monitors process's timeliness in accordance with contractor standards.
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
• Utilizes allocated resources to back up review determination.
• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.
• May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.
• Performs screenings/assessments and determines risk via telephone.
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.
• Provides education to members and their families/caregivers.
• Reviews first level appeal and ensures utilization OR claim review provides thorough documentation of each determination and basis for each.
• Conducts research necessary to make thorough/accurate basis for each determination made.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Participates in all Required Licenses and Certificates.
  
  

To Qualify For This Position, You Will Need

• Bachelors in a job-related field.
• Two years clinical experience.
• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical OR critical thinking skills.
• Ability to handle confidential OR sensitive information with discretion.
• Ability to remain in a stationary position and operate a computer.
• Microsoft Office.
• Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire.
  
  

What We Prefer

• Associate Degree – Nursing OR Graduate of an Accredited School of Nursing.
• Working knowledge of spreadsheet and database software.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, OR influence others.
• Knowledge of Microsoft Excel, Access, OR other spreadsheet/database software.
• Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
  
  

What We Can Do for You

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.
  
  

What To Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.