Medical Claims & Utilization Reviewer I

Southcarolinablues; Columbia (SC); Sur place; USD 25 000 - 35 000; Plein temps

Résumé du poste

BlueCross BlueShield of South Carolina seeks a Reviewer I, Medical to perform medical reviews and utilization management for professional, inpatient, or outpatient services. You will document decisions using clinical guidelines and support claims and utilization practices, while maintaining high standards of accuracy and compliance.

The role emphasizes education to members and providers, adherence to timelines, and collaboration across teams in a full-time office setting in Columbia, SC.

Qualifications

• 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.

Responsabilités

• Performs medical claim reviews and makes payment determinations.
• Monitors timeliness and conducts authorization for services within guidelines.
• Provides education to members and families on determinations and coverage.

Connaissances

Word processing

Judgment

Customer service

Spelling/grammar

Analytical thinking

Discretion

Confidentiality

Formation

Bachelor's degree - Social Work

LPN/LVN diploma

Associate Nursing degree

Outils

Microsoft Office

Description du poste

BlueCross BlueShield of South Carolina seeks a Reviewer I, Medical to perform medical reviews and utilization management for professional, inpatient, or outpatient services. You will document decisions using clinical guidelines and support claims and utilization practices, while maintaining high standards of accuracy and compliance.

The role emphasizes education to members and providers, adherence to timelines, and collaboration across teams in a full-time office setting in Columbia, SC.