Medical Reviewer I: Claims & Utilization Expert

ourhrconnect; United States; Hybrid; USD 60,000 - 90,000; Full time

Benefits offered by this job

Tuition reimbursement

Skills training classes

Aspiring leaders' program

Promotional opportunities

Evenings, weekends and holidays off

Job summary

BlueCross BlueShield of South Carolina is seeking a Medical Claims Reviewer to join our team. You will perform medical claim reviews and utilization management for professional and facility benefits, using established criteria sets and clinical guidelines to determine medical necessity.

This onsite role at Myrtle Beach, SC, starts with 8:00 am–5:00 pm, Monday–Friday, with remote work after six months of onsite training. A U.S.

Qualifications

• Experience in medical claims review and utilization management.
• Familiarity with professional and facility benefits and clinical guidelines.
• Ability to document decisions using protocol sets.

Responsibilities

• Performs medical claim reviews and makes determinations of medical necessity.
• Monitors timeliness and conducts authorization processes within guidelines.
• Educates members and providers; supports quality control activities.
• Provides review documentation and participates in utilization management.

Job description

BlueCross BlueShield of South Carolina is seeking a Medical Claims Reviewer to join our team. You will perform medical claim reviews and utilization management for professional and facility benefits, using established criteria sets and clinical guidelines to determine medical necessity.

This onsite role at Myrtle Beach, SC, starts with 8:00 am–5:00 pm, Monday–Friday, with remote work after six months of onsite training. A U.S.