Medical Utilization Review Specialist — Remote

001 BlueCross and BlueShield of South Carolina; Myrtle Beach (SC); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

PTO

On-site cafeterias & fitness centers

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking a medical reviewer to assess medical necessity and perform utilization management across professional, inpatient, and outpatient services. The role emphasizes communication with members and providers, documentation of determinations, and adherence to guidelines.

Remote work follows an initial on-site period, with a clear career development path. The position requires a Bachelor’s degree in Social Work or a licensure pathway (LPN/LVN or RN/LBSW)

Qualifications

• Bachelor's degree in Social Work or equivalent.
• 2 years clinical experience.
• Active licensure as LPN/LVN, LBSW, or RN may be required depending on unit.

Responsibilities

• Performs medical claim reviews and determines payment.
• Monitors timeliness of processes per contractor standards.
• Performs authorization to ensure coverage per guidelines.
• Reviews medical information and documents determinations thoroughly.
• Educates members and families on coverage and care.

Skills

Word processing

Good judgment

Customer service

Spelling & grammar

Analytical thinking

Discretion

Computer operation

Education

Bachelor's degree - Social Work

LPN/LVN licensure

LBSW licensure

RN licensure

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a medical reviewer to assess medical necessity and perform utilization management across professional, inpatient, and outpatient services. The role emphasizes communication with members and providers, documentation of determinations, and adherence to guidelines.

Remote work follows an initial on-site period, with a clear career development path. The position requires a Bachelor’s degree in Social Work or a licensure pathway (LPN/LVN or RN/LBSW)