Medical Reviewer I

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.

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-based objectives.
• Participates in all required training.

To Qualify for This Position, You Will Need:

• Bachelor's degree - Social Work, OR Graduate of an Accredited School of Licensed Practical Nursing OR Licensed Vocational Nursing.
• Two years' clinical experience.
• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical OR critical thinking skills.
• Ability to handle confidential OR sensitive information with discretion.
• Ability to remain in a stationary position and operate a computer.
• Microsoft Office.
• Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire.

What We Prefer:

• Active, unrestricted LPN/RN compact multistate license strongly preferred.
• Five years nursing experience in varied nursing settings including medical/surgical or utilization review.
• Ability to work with multiple windows-based programs simultaneously.
• Intermediate spreadsheet, word processing and outlook experience.

What We Can Do for You

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email or call , ext with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information .

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