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. You will also ensure appropriate levels of healthcare services are provided.

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 through Friday and will be fully remote (W@H) upon the completion of onsite training at 17 Technology Circle, Columbia, S.C., 29203.

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 interworking 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:

• Associates in a job-related field.

• Graduate of Accredited School of Nursing.

• Four years clinical, OR two years clinical and two years medical review/utilization review, OR combination of health plan, clinical, and business experience totaling four years.

• Working knowledge of managed care and various forms of health care delivery systems.

• Strong clinical experience to include home health, rehabilitation, and/or b