We are currently hiring for a Medical Reviewer I to join Blue Cross Blue Shield of South Carolina. In this role as a Medical Reviewer I, you will perform medical reviews using established criteria sets and/or perform utilization management of professional, inpatient, or 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.

Why should you join the Blue Cross Blue Shield 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.

• 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.

• 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.

• Associate degree – Nursing OR Graduate of an Accredited School of Nursing.
• Working knowledge of spreadsheet and database software.
• Demonstrated oral and written communication skills.
• Claims Processing experience.
• Ability to persuade, negotiate, OR influence others.
• Knowledge of Microsoft Excel, Access, OR other spreadsheet/database software.
• Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

• 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.