Summary
 

We are currently hiring for a Medical Reviewer I to join BlueCross BlueShield of South Carolina. In this role as 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. You will also document decisions using indicated protocol sets or clinical guidelines and provide 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 for more than seven decades we’ve been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics

This position is full time (40 hours/week) Monday-Friday and will be located at 4101 Percival Road, Columbia, S.C., 29229.

What You Will Do:

• May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination.

• Monitors process's timeliness in accordance with contractor standards.

• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.

• Utilizes allocated resources to back up review determination.

• Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.

• May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.

• Performs screenings/assessments and determines risk via telephone.

• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.

• Provides education to members and their families/caregivers.

• Reviews first level appeal and ensures utilization OR claim review provides thorough documentation of each determination and basis for each.

• Conducts research necessary to make thorough/accurate basis for each determination made.

• 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 Will Need:

• Bachelors in a job-related field.

• Two years clinical experience.

• Working knowledge of word processing software.

• Good judgment skills. 

• Demonstrated customer service and organizationa