Medical Claims & Utilization Reviewer (Remote After Training)

ourhrconnect; Myrtle Beach (SC); Remote; USD 55,000 - 75,000; Full time

Benefits offered by this job

Health plans

401k with match

Life Insurance

Paid Time Off

Job summary

BlueCross BlueShield of South Carolina is seeking a Medical Reviewer to evaluate medical records for medical necessity and manage utilization of professional, inpatient, and outpatient services. You will document decisions using clinical guidelines and support medical claims reviews.

Remote after six months of onsite training, with a Monday–Friday schedule. This role requires US citizenship and active licensure as LPN/LVN or LBSW, plus a Bachelor's degree in Social Work or related nursing

Qualifications

• Bachelor's degree in Social Work or nursing licensure required.
• At least 2 years of clinical experience.
• Active US LPN/LVN or LBSW licensure required.
• Proficient in MS Office.

Responsibilities

• Perform medical claim reviews and utilization management.
• Document decisions using protocol sets and guidelines.
• Educate staff and participate in quality controls.

Skills

Medical reviews

Utilization management

Documentation

Communication

Education

Bachelor's degree - Social Work

LPN/LVN diploma

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a Medical Reviewer to evaluate medical records for medical necessity and manage utilization of professional, inpatient, and outpatient services. You will document decisions using clinical guidelines and support medical claims reviews.

Remote after six months of onsite training, with a Monday–Friday schedule. This role requires US citizenship and active licensure as LPN/LVN or LBSW, plus a Bachelor's degree in Social Work or related nursing