Summary
 

We are currently hiring for a Medical Review Manager to join BlueCross BlueShield of South Carolina. In this role as Medical Review Manager, you will oversee the accurate processing of claims that have been deferred for medical necessity review, ensure compliance with nationally recognized standards, and local, state, and federal laws and regulations while identifying and implementing process improvement opportunities.

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. 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 8733 Highway 17 Bypass, Myrtle Beach, S.C., 29575.

What You Will Do:

• Manages the medical review process.
• Maintains a well-trained staff.
• Develops/implements medical review strategy with the ultimate goal of reducing the error rate.
• Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations.
• Identifies missed standards and implements corrective actions.
• Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action.
• Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner.
• Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required to build and maintain positive customer relationships.

To Qualify for This Position, You Will Need:

• Associates in a job-related field.
• Graduate of Accredited School of Nursing (Equivalency not applicable for the Celerian Group OR Palmetto GBA. Bachelor's degree required.)
• Five years clinical and utilization review to include two years supervisory, OR team lead experience, OR equivalent military experience in grade E4 OR above.
• Excellent verbal and written communication, organizational, customer service, analytical, OR critical thinking, and presentation skills.
• Good judgment skills.
• Proficient spelling, grammar, punctuation, and basic business math.
• Ability to persuade, negotiate OR influence, and handle confidential, OR sensitive information with discretion.
• Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes.
• Microsoft Office.
• Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

What We Prefer

• TRICARE experience.

What We Can Do for You:

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