Summary
 

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.

Our ideal candidate will possess the following experience:

- Four years of recent clinical experience in a defined Behavioral Health specialty area. Specialty areas include: Serious Mental Illness (SMI), Trauma and Post-Traumatic Stress Disorder, Substance Use Disorders (SUD), Child and Adolescent Behavioral Health, and Cognitive Disorders. Or, 4 years of Behavioral Health utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.

Description
 

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 occassionally, 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.

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

• Required Education: Associates in a job-related field

• Degree Equivalency: Graduate of Accredited School of Nursing

• Required Work Experience: 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.

• Required Skills and Abilities: 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 discreti