Summary
 

 Join our team serving active and retired US military members and their covered family members. We strive to ensure that these dedicated individuals and their loved ones receive high-quality care administered as economically as possible and in accordance with current evidence-based care guidelines. As part of our expanding team of medical reviewers, you will evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices.

In addition to being able to serve those who protect our country, you won’t have the physical stress of working in a direct care setting and you will have nights, weekends, and holidays off to spend with those you love. For those wanting to grow their career with us, we offer tuition reimbursement, skills training classes, an aspiring leaders’ program, and promotional opportunities throughout our family of companies. In these uncertain times, we are a solid company who has served individuals, businesses, associations, and the US government for over 70 years. Our leadership is committed to ensuring that we will be serving our customers for another 70 years.

Description
 

Logistics

• Full-time hourly position (40 hours/week).
• Onsite in our office at located at 8733 Highway 17 Bypass, Myrtle Beach, S.C., 29575
• Work hours: 8:00 am to 4:30 pm Monday through Friday.
• Due to TRICARE security access requirements for this position, the selected candidate must be a U.S. citizen, complete a Department of Defense SF85 or SF86 form via the electronic system eAPP, Declaration for Federal Employment Form OF 306 and submit two fingerprint cards. The U.S. government will be completing a thorough background investigation on the candidate selected for this position.

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-bas