[Hiring] Senior Medical Reviewer @Palmetto GBA

Role Description

Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided.

This position is part of the End-Stage Renal Disease QIP Contract.

Logistics:

• Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

Functions as a team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. 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 (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews.
• Follows a process to ensure quality plan is adhered to and communicated to all parties.
• 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.

Qualifications

• Associate Degree - Nursing OR Graduate of Accredited School of Nursing.

Requirements

• Four years of clinical experience, 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.

Preferred Requirements

• ESRD/renal dialysis experience.
• Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting.
• Three or more years’ education/training/consulting experience related to Dialysis services (may be concurrent).
• Three or more years’ experience in quality management coordination related to Dialysis services (may be concurrent).

Required Skills and Abilities

• Working knowledge of managed care and various forms of healthcare 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.

Required Software and Tools

• Microsoft Office.

Required License and Certificate

• 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).