We are currently hiring for an RN Medical Reviewer III to join BlueCross BlueShield of South Carolina. In this role as an RN Medical Reviewer III, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, document decisions using indicated protocol sets or clinical guidelines, and provide support and review of medical claims and utilization practices.
Location:
This position is full-time (40 hours/week) Monday-Friday, working an 8-hour shift between 6:00am - 5:00pm and will be fully remote after 1-2 weeks of on-site training in Columbia, SC. The candidate will be required to report on-site occasionally for trainings, meetings, or other business needs.
Responsibilities
Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
To Qualify for This Position, You'll Need the Following:
Required Education: Associates in a job-related field
Degree Equivalency: Graduate of Accredited School of Nursing
Required Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience.
Required Skills and Abilities: Working knowledge of managed care and various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same.
Working knowledge of word processing software.
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment skills.
Demonstrated customer service and organizational skills.
Demonstrated oral and written communication skills.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Required Software and Tools: Microsoft Office.
What We Prefer You to Have:
Preferred Work Experience: Well-rounded adult, clinical experience (i.e., medical-surgical, ER, critical care)
Preferred Skills and Abilities: Knowledge of spreadsheet and database software.
Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review.
Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet database software.
Our Comprehensive Benefits Package Includes the Following:
We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.
Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
What We Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
Benefits
Health insuranceDental insuranceVision insurance401(k)Paid time offRemote work options
Ourhrconnect · W@h South Carolina