Reviewer I, Medical - Request #37813186

Southcarolinablues; Columbia (SC); On-site; USD 25,000 - 35,000; Full time

Job summary

BlueCross BlueShield of South Carolina seeks a Reviewer I, Medical to perform medical reviews and utilization management for professional, inpatient, or outpatient services. You will document decisions using clinical guidelines and support claims and utilization practices, while maintaining high standards of accuracy and compliance.

The role emphasizes education to members and providers, adherence to timelines, and collaboration across teams in a full-time office setting in Columbia, SC.

Qualifications

• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to remain in a stationary position and operate a computer.

Responsibilities

• Performs medical claim reviews and makes payment determinations.
• Monitors timeliness and conducts authorization for services within guidelines.
• Provides education to members and families on determinations and coverage.

Skills

Word processing

Judgment

Customer service

Spelling/grammar

Analytical thinking

Discretion

Confidentiality

Education

Bachelor's degree - Social Work

LPN/LVN diploma

Associate Nursing degree

Tools

Microsoft Office

Job description

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we've been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we're stronger than ever. Our A.M. Best rating is A+ (Superior), making us the only health insurance company in South Carolina with that rating. 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 that allow us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Job Title: Reviewer I, Medical

Position Details:

• Bill Rate: $35.65/hour

Position Summary:

Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.

Essential Duties and Responsibilities:

• 80% May provide any of the following in support of medical claims review and utilization review practices: Performs medical claim reviews and makes a reasonable charge payment determination. Monitors process's timeliness in accordance with contractor standards. Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines. Utilizes allocated resources to back up review determination. Reviews interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process. May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs. Performs screenings/assessments and determines risk via telephone. Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services. Provides education to members and their families/caregivers. Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each. Conducts research necessary to make thorough/accurate basis for each determination made.
• 10% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines. Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations.
• 10% Participates in quality control activities in support of the corporate and team-based objectives. Participates in all required training.

Required Skills and Abilities:

• Working knowledge of word processing software.
• Good judgment skills.
• Demonstrated customer service and organizational skills.
• Demonstrated proficiency in spelling, punctuation, and grammar skills.
• Analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to remain in a stationary position and operate a computer.

Preferred Skills and Abilities:

• Working knowledge of spreadsheet and database software.
• Demonstrated oral and written communication skills.
• Ability to persuade, negotiate, or influence others.

Required Software and Other Tools:

• Microsoft Office.

Preferred Software and Other Tools:

• Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

Work Environment:

Typical office environment; some travel between office buildings.

Required Education:

Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.

Preferred Education:

Associate Degree - Nursing OR Graduate of an Accredited School of Nursing.

Required Experience:

2 years clinical experience.

Required Licenses and Certificates:

• Active, unrestricted LPN/LVN licensure from the United States and in the state of hire, OR
• Active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC), OR
• Active, unrestricted LBSW (Licensed Bachelor of Social Work) licensure from the United States and in the state of hire.

Preferred Licenses and Certificates:

• Active, unrestricted RN licensure from the United States and in the state of hire, OR
• Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

Minimum Required Work Experience:

2 years clinical experience.

Pay Transparency:

• This is the pay range that Magnit reasonably expects to pay someone for this position: $17.82/hour - $25.46/hour W-2.
• Benefits: Medical, Dental, Vision, 401K (provided minimum eligibility hours are met).

BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We've found dedication, work ethics 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.