Medical Review Manager

001 BlueCross and BlueShield of South Carolina; Myrtle Beach (SC); On-site; USD 90,000 - 130,000; 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 processing of claims deferred for medical necessity review. The role ensures compliance with federal and state regulations and improves processes for accuracy and speed.

Applicants should have extensive clinical/utilization review experience, strong leadership, and expertise in communicating with providers and regulatory bodies. This on-site role is based in Myrtle Beach, SC with standard 40-hour weeks.

Qualifications

• 5 years clinical and utilization review experience including 2 years of supervisory or team lead experience
• RN licensure active in state hired or active compact multistate RN license (NLC)
• Knowledge of government programs, medical terminology, and litigation processes

Responsibilities

• Manages the medical review process.
• Maintains a well-trained staff.
• Develops/implements medical review strategy to reduce error rate.
• Ensures timeliness of review and quality of decisions while complying with laws and standards.
• Interfaces with appellants, attorneys, and regulatory bodies as needed.

Skills

Communication skills

Analytical thinking

Leadership

Organization

Presentation skills

Discretion

Education

Associate's degree in related field

Bachelor's degree

Nursing degree (RN)

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.

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.

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

• 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.

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 [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.

Veterans Welcome!

BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full‑time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.

Join Us

If you’re ready to join in a diverse company with secure, community roots and an innovative future, consider joining our team.