Senior Medical Reviewer

🔥 0 minutes ago

🌴 South Carolina – Remote

🌴 South Carolina – Remote

⏰ Full Time

🟠 Senior

🔍🏥 Medical Reviewer

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Insurance • Finance

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas • Provides leadership/guidance/direction/training to staff • Maintains a working knowledge of unit functions and the ability to interpret to new hires • Acts as a resource for staff/external entities troubleshooting as well as resolving issues • Keeps manager informed of any problems/issues that need resolving • Assists management with monitoring workflow and workloads • Participates in departmental quality reviews • Follows a process to ensure quality plan is adhered to • Gives/receives feedback regarding medical review decision making and technical claims processing issues • Ensures that quality work instructions/forms/documents are developed/revised as needed • Provides quality service and communicates effectively with external/internal customers in response to inquiries • Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems • Participates in compliance initiatives and other directed activities • Participates/oversees special projects as requested by management

🎯 Requirements

• Associate Degree - Nursing OR Graduate of Accredited School of Nursing • Four years of clinical OR Two years of clinical and two years of medical review/utilization review OR Combination of health plan, clinical, and business experience totaling four years • ESRD/renal dialysis experience preferred • Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting preferred • Three or more years’ education/training/consulting experience related to Dialysis services preferred • Three or more years’ experience in quality management coordination related to Dialysis services preferred • 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 and spreadsheet software • Ability to work independently, prioritize effectively, and make sound decisions • Good judgment skills • Demonstrated customer service, organizational, and presentation skills • Demonstrated proficiency in spelling, punctuation, and grammar 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 • Ability to lead/direct/motivate others • 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

🏖️ Benefits

• Health insurance • 401(k) matching • Paid time off • Flexible work arrangements • Professional development