Medical Reviewer I
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Remote
Location: South Carolina • United States
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About the role
- Evaluate medical records to determine medical necessity
- Perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals
- Document decisions using indicated protocol sets or clinical guidelines
- Provide support and review of medical claims and utilization practices
- Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
- Monitor process's timeliness in accordance with contractor standards
- Conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs
- Provide education to members and their families/caregivers
- Review first level appeal and ensure thorough documentation of each determination and basis for each
Requirements
- Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing
- 2 years clinical experience
- 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
- Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, 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
Benefits
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
medical record evaluationutilization managementmedical claims reviewauthorization processhigh dollar forecastingpatient health summariesclinical guidelinesdocumentation protocolsconfidential information handlingword processing software
Soft Skills
good judgmentcustomer serviceorganizational skillsanalytical thinkingcritical thinkingdiscretioncommunication skillseducation provisionattention to detailtimeliness
Certifications
LPN licensureLVN licensureLBSW licensureBachelor's degree in Social WorkGraduate of Accredited School of Nursing