Remote Physician Advisor — Utilization & Policy

001 BlueCross and BlueShield of South Carolina; South Carolina; Hybrid; USD 176,000 - 355,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off

Education Assistance

Job summary

BlueCross BlueShield of South Carolina is seeking a Physician Advisor to optimize utilization management, ensure medical necessity, and support documentation and coding improvements. In this full-time remote role, you will collaborate with a multidisciplinary team to implement care management protocols and ensure quality care for all patients.

The ideal candidate holds an MD or DO license, with 8 years of broad clinical experience, including utilization review.

Qualifications

• MD/DO with current license to practice (US).
• 8 years broad clinical experience including utilization and medical review.
• Strong communication, judgment, organizational, analytical, and presentation skills.

Responsibilities

• Communicates with hospital physicians, care coordination and UM staff to champion evidence-based care and documentation.
• Guides physician practice patterns, resource utilization, medical necessity, documentation best practices, and compliance with regulations.
• Performs UM reviews including pre-admission, continued stay, precertifications, post-service reviews, ER reviews, and case management.
• Responds to requests for clinical reviews on medical necessity or other reasons within the Case Management department.
• Keeps abreast of CMS and MCG guidelines to support UM decisions.
• Maintains compliance with legal, regulatory and accreditation requirements and payor policies.
• Uses and protects PHI per HIPAA standards.
• Acts as medical resource for quality improvement and as liaison to medical community.

Skills

Verbal & written communication

Judgment & Organization

Analytical thinking

Strategic concepts

Negotiation

Multitasking

Education

MD or DO

Tools

Microsoft Office

Job description

BlueCross BlueShield of South Carolina is seeking a Physician Advisor to optimize utilization management, ensure medical necessity, and support documentation and coding improvements. In this full-time remote role, you will collaborate with a multidisciplinary team to implement care management protocols and ensure quality care for all patients.

The ideal candidate holds an MD or DO license, with 8 years of broad clinical experience, including utilization review.