Medical Review Manager

RiseMe; Myrtle Beach (SC); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking a Medical Review Manager to oversee the medical necessity reviews for deferred claims. You will lead a trained team, ensuring accurate reviews, timely decisions, and adherence to federal, state, and industry standards.

The role requires RN licensure and 5 years in clinical/utilization review with supervisory experience, plus strong communication and analytical skills.

Qualifications

• Bachelor's degree required for the Celerian Group.
• RN licensure in state hired or compact multistate license.
• 5 years clinical and utilization review experience with 2 years supervisory/leadership.
• Strong communication, organization, analytical and presentation skills.

Responsibilities

• Oversee medical review process and staff training; develop review strategy.
• Ensure timeliness, quality, and compliance with laws and standards; corrective actions.
• Provide feedback to providers; respond to inquiries promptly.

Skills

Verbal and written communication

Organizational skills

Customer service

Analytical thinking

Presentation skills

Judgment

Confidentiality

Persuasion/ negotiation

Education

Associate's degree in a related field

Bachelor's degree required for Celerian Group

RN licensure in state hired / compact multistate RN license

Tools

Microsoft Office

Job description

Summary

We are currently hiring for a Medical Review Manager to join BlueCross BlueShield of South Carolina. In this role as a Medical Review Manager, you will oversee the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities.

Description

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose:

We are currently hiring for a Medical Review Manager to join BlueCross BlueShield of South Carolina. In this role as a Medical Review Manager, you will oversee the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities.

Logistics:

https://corporate.palmettogba.com/ - one of BlueCross BlueShield of South Carolina’s subsidiary companies.

Location:

This position is full-time (40-hours/week) Monday-Friday from 8:00am-5:00pm and will be on-site in Myrtle Beach, SC.

What You’ll Do:

• Manages the medical review process. Maintains a well-trained staff. Develops/implements medical review strategy with the ultimate goal of reducing the error rate. Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations. Identifies missed standards and implements corrective actions.
• Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action. Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner.
• Interfaces with internal and external customers such as appellants/attorneys, congressional offices , and other regulatory bodies as required to build and maintain positive customer relationships.

To Qualify for This Position, You'll Need the Following:

• Required Education: Associate's in a job related field (Bachelor's degree required for the Celerian Group).
• Degree Equivalency: Graduate of Accredited School of Nursing (Equivalency not applicable for the Celerian Group or Palmetto GBA. Bachelor's degree required.)
• Required Work Experience: 5 years clinical and utilization review to include 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above.
• Required Skills and Abilities: Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills.
• Good judgment skills.
• Proficient spelling, grammar, punctuation, and basic business math.
• Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion.
• Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

What We Prefer You to Have:

• Previous TRICARE experience

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

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 our recruiter to verify resume specifics and salary requirements.

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 disabilitiesand 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 [e-mail] or call 800-288-2227, ext. 47480 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 moreinformation.

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