Medical Reviewer I

BlueCross BlueShield of South Carolina

Performs medical reviews and utilization management of facility benefits and services. Supporting medical claims reviews and providing documentation according to clinical guidelines.

Posted 7/8/2026full-timeMyrtle Beach • South Carolina • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

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.
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.
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.
Participates in quality control activities in support of the corporate and team-based objectives.

Requirements

What you’ll need

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 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.

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

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Applicant Tracking System Keywords

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Hard Skills & Tools

Medical Claims ReviewAuthorization ProcessRisk AssessmentDocumentation ProtocolsCoding Procedures

Soft Skills

Good JudgmentCustomer ServiceOrganizational SkillsCritical ThinkingDiscretion

Certifications

Active LPN/LVN LicensureActive LBSW Licensure