Summary
 

We are currently hiring for a Medical Reviewer III to join BlueCross BlueShield of South Carolina. In this role as a Medical Reviewer III, you will perform medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines, document decisions using indicated protocol sets or clinical guidelines, and provide support and review of medical claims and utilization practices.

Description
 

Location:

This position is full-time (40 hours/week) Monday-Friday with an 8-hour shift from 6:00am-5:00pm EST and will be fully remote. Candidates may be asked to report on-site occasionally for trainings, meetings, or other business needs.

What You’ll Do:

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned 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 Experience: 2 years clinical plus 1 year utilization/medical review, quality assurance, or home health, OR 3 years clinical. FOR PALMETTO GBA (CO. 033) ONLY: 2 years clinical experience plus 2 years utilization/medical review, quality assurance, or home health experience.
• 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 software. 
• Ability to work independently, prioritize effectively, and make sound decisions. 
• Good judgment skills. 
• Demonstrated customer service and organizational 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 discretion.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: