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Senior Medical Reviewer – Behavioral Health Focused
BlueCross BlueShield of South CarolinaSenior Medical Reviewer leading Behavioral Health specialty programs and overseeing medical review processes. Ensures quality healthcare services as part of BlueCross BlueShield of South Carolina.
About the role
Key responsibilities & impact- Functions as team leader/senior-level Medical Reviewer.
- Provides leadership/guidance/direction/training to staff.
- Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow.
- Acts as 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 (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
- Participates in departmental quality reviews.
- Follows process to ensure quality plan is adhered to and communicated to all parties.
- Gives/receives feedback regarding medical review decision making and technical claims processing issues.
- Ensures that quality work instructions/forms/documents are developed/revised as needed.
- Provides quality service and communicates effectively with external/internal customers in response to inquiries.
- Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
- Participates in compliance initiatives and other directed activities.
- Participates/oversees special projects as requested by management.
Requirements
What you’ll need- Four years of recent clinical experience in a defined Behavioral Health specialty area. Specialty areas include: Serious Mental Illness (SMI), Trauma and Post-Traumatic Stress Disorder, Substance Use Disorders (SUD), Child and Adolescent Behavioral Health, and Cognitive Disorders.
- Or, 4 years of Behavioral Health utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.
- Associates in a job-related field
- Graduate of Accredited School of Nursing
- 4 years clinical, OR, 2 years clinical and 2 years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years.
- Working knowledge of managed care and various forms of health care 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.
- If RN, 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), OR active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
Benefits
Comp & perks- 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
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
Behavioral Health Specialty KnowledgeUtilization Review/Case ManagementQuality Assurance ProcessesMedical Review Decision MakingHealth Care Delivery Systems Knowledge
Soft Skills
Effective CommunicationCustomer ServiceOrganizational SkillsJudgment SkillsAbility to Persuade and Negotiate
Certifications
Active RN LicensureCertification in Specialty Area