[Hiring] Senior Medical Reviewer @BlueCross BlueShield of South Carolina

Role Description

We are currently hiring for a Senior Medical Reviewer to join BlueCross BlueShield of South Carolina. In this role as a Senior Medical Reviewer, you will act 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 and ensure appropriate levels of healthcare services are provided.

Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote in SC. Our ideal candidate must reside in South Carolina and may be required to report on-site occasionally, and will oversee member-facing patient visits by team members within SC.

What You’ll Do:

• Functions as team leader/senior-level Medical Reviewer.
• Provides leadership/guidance/direction/training to staff.
• Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow.
• Acts as 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 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

• Associates in a job-related field.
• Graduate of Accredited School of Nursing.

Requirements

• 4 years clinical, OR, 2 years clinical and 2 years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years.
• 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.

Benefits

• 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.