FREE ACCESS
5,000–10,000 jobs/day
See all jobs on JobTailor
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Senior Medical Reviewer
BlueCross BlueShield of South CarolinaTeam Lead Medical Reviewer providing leadership and training in specialty programs for BlueCross BlueShield of SC. Ensuring quality healthcare services and compliance with review processes.
About the role
Key responsibilities & impact- Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas.
- Provides leadership/guidance/direction/training to staff.
- Maintains a working knowledge of unit functions and the ability to interpret to new hires.
- Acts as a resource for staff/external entities troubleshooting as well as resolving issues.
- Keeps manager informed of any problems/issues that need resolving.
- Assists management with monitoring workflow and workloads.
- Participates in departmental quality reviews.
- Gives/receives feedback regarding medical review decision making and technical claims processing issues.
- Participates in compliance initiatives and other directed activities.
- Participates/oversees special projects as requested by management.
Requirements
What you’ll need- Associate Degree - Nursing OR Graduate of Accredited School of Nursing.
- Four years of clinical experience, OR Two years of clinical and two years of medical review/utilization review, OR Combination of health plan, clinical, and business experience totaling four years.
- Preferred: ESRD/renal dialysis experience, Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting, Three or more years’ education/training/consulting experience related to Dialysis services, Three or more years’ experience in quality management coordination related to Dialysis services.
- Working knowledge of managed care and various forms of healthcare delivery systems.
- Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
- Knowledge of specific criteria/protocol sets and the use of the same.
- Working knowledge of word processing and spreadsheet software.
- Ability to work independently, prioritize effectively, and make sound decisions.
- Good judgment skills.
- Demonstrated customer service, organizational, and presentation skills.
- Demonstrated proficiency in spelling, punctuation, and grammar skills.
- Demonstrated oral and written communication skills.
- Ability to persuade, negotiate, or influence others.
- Analytical or critical thinking skills.
- Ability to handle confidential or sensitive information with discretion.
- Ability to lead/direct/motivate others.
- 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.
Benefits
Comp & perks- Health insurance
- Retirement plans
- Paid time off
- Flexible work arrangements
- Professional development
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
Clinical ExperienceQuality ManagementUtilization ManagementMedical ReviewAnalytical SkillsDecision MakingKnowledge of Protocol SetsHome Health ExperienceRehabilitation ExperienceBroad Medical Surgical Experience
Soft Skills
LeadershipCustomer ServiceOrganizational SkillsPresentation SkillsCommunication Skills
Certifications
Active RN LicensureNurse Licensure Compact License