Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.

Location: This position is full-time (40-hours/week) Monday-Friday working REMOTE in the United States or ONSITE at our GPC location at 17 Technology Circle, Columbia, SC. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM.

What You’ll Do:

• Supports operations in the form of case review on both medical and regulatory matters.

• Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.

• Educates staff and medical community on various aspects of medical policy and program administration.

• May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.

• Develops external relationships with the medical community and serves as liaison between these entities and the contractors.

• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.

• Conducts research into new or controversial medical procedures and technology.

 To Qualify for This Position, You'll Need the Following:

• Required Education: Doctorate in a job related field.

• Required Experience:

  • 5 years post graduate experience in direct patient care.

• Required Software and tools: Microsoft Office

• Required Skills and Abilities:

  • Excellent verbal and written communication skills.

  • Excellent customer service, organizational, and presentation skills.

  • Good judgment skills. Proficiency in spelling, punctuation, and grammar.

  • Ability to persuade, negotiate, or influence others.

  • Ability to work as a team member as well as a leader.

  • Knowledge of medical and utilization review techniques.

• Required Licenses and Certifications: Active state medical license and current board certification in a recognized specialty.

We Prefer That You Have the Following:

• Health insurance industry experience

• Experience in INPATIENT Rehabilitation

• Medicare policy knowledge and experience

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the first of the month following 28 days of employment.  

• 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

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or