Reviewer I, Medical

About the role

Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides 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 we've been part of the national landscape for more than seven decades, 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices. Logistics: PGBA - one of BlueCross BlueShield of South Carolina's subsidiary companies. Location: This is an onsite position located at 8733 Highway 17 Bypass, Myrtle Beach, S.C., 29575. The hours are 8:00am - 5pm, Monday through Friday. This position will be remote after 6 months of onsite training. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act ( SCA ) . As a Service Contract Act (SCA) employee , you are required to e nroll in our health insurance , even if you already have other health insurance . Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment.