We are currently hiring for a Medical Reviewer I to join BlueCross BlueShield of South Carolina. In this role as a 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, 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 from 8:00 am - 4:30 pm and will be fully remote in South Carolina.
Responsibilities
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'll Need the Following:
Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
Required Experience: 2 years clinical experience.
Required Software and Tools: Microsoft Office.
We Prefer That You Have the Following:
Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing.
Preferred Skills and Abilities: Working knowledge of spreadsheet and database software. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others.
Preferred Software and Others Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
Preferred Licenses and Certificates: 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).
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.
What To Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure you meet the qu
Benefits
Health insuranceDental insuranceVision insurance401(k)Paid time offRemote work options
Ourhrconnect · W@h South Carolina