BlueCross BlueShield of South Carolina

Medical Reviewer

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.

Medical Reviewer II – Prior-Auth A/B MAC

Administration

• Integrate clinical and medical data with automated technologies to support healthcare operations and informatics
• Act as a liaison between clinical expertise, data systems, and regulatory standards to ensure compliance and improve service delivery
• Evaluate system performance, validate workflows, and drive process improvements that enhance provider and patient experiences while reducing compliance risk
• Submit IT data requests, conduct validity testing, perform quality check processes, manage escalations, contribute to process improvements, and communicate updates to key stakeholders
• Analyze prior authorization and code set data to ensure alignment with clinical guidelines, regulatory standards, contracts, and operational requirements
• Partner with operations, IT, and vendors to implement and validate clinical decision rules and workflows that support strategic and regulatory objectives
• Identify opportunities to enhance automation, reduce provider friction, and improve service turnaround times through collaboration with internal teams and external partners
• Monitor data quality and develop reporting tools for leadership and compliance purposes
• Translate complex clinical and data insights into actionable strategies
• Evaluate system enhancements and participate in testing and validation activities to ensure successful implementation and continuous improvement

RN Medical Informatics Administrator – Anywhere

Auditor

• Conducts audits of the financial, management, and administrative procedures of assigned divisions, providers, departments, and various lines of businesses throughout the organization to ensure that procedures are in compliance
• Audits include interviewing key personnel, conducting testing, evaluating internal controls, analyzing existing financial and management practices to determine effectiveness, and reviewing relevant documentation to support findings
• Develops detailed reports on each audit conducted
• Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes
• Conducts testing of corrective actions as identified
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud
• Prepares reports of finding and recommendations for management
• Assists other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel

Auditor I – Cost Reporting

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.

RN Medical Reviewer II

Medical Director

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on issues concerning medical policies
• Writes and revises medical policies
• Supports operations in the form of case review on both medical and regulatory matters
• Develops claim adjudication criteria for situations requiring medical judgment
• Provides input on issues and operational policies, processes, and procedures
• Educates staff and medical community on various aspects of medical policy and program administration
• Develops and updates medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies
• Develops external relationships with the medical community and serves as liaison between these entities and the contractors
• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization
• Conducts research into new or controversial medical procedures and technology

Medicare Medical Director

• Perform medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations
• Make reasonable payment determinations based on clinical medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement
• Monitor process’s timeliness in accordance with contractor standards
• Document medical rationale to justify payment or denial of services and/or supplies
• Educate internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participate in quality control activities supporting corporate and team-based objectives
• Provide guidance, direction, and input as needed to LPN team members
• Provide education to non-medical staff through discussions, team meetings, classroom participation, and feedback
• Assist with special projects and specialty duties and responsibilities as assigned by management

RN Medical Reviewer II – RCD Medicare

• Provides administrative oversight to the medical staff
• Analyzes medical review utilization data
• Researches new medical procedures or technology
• Acts as a resource to providers and internal staff on medical policies
• May write and revise medical policies
• Develops claim adjudication criteria
• Provides input on operational policies, processes, and procedures
• Educates staff and medical community on medical policy and program administration
• Develops external relationships with the medical community
• Reviews physician and provider practice pattern analysis and other statistical data
• Conducts research into new or controversial medical procedures and technology

Molecular Diagnostics Medical Director

• Conducts audits of the financial, management, and administrative procedures of assigned divisions, providers, departments, and various lines of businesses throughout the organization to ensure that procedures are in compliance.
• Audits include interviewing key personnel, conducting testing, evaluating internal controls, analyzing existing financial and management practices to determine effectiveness, and reviewing relevant documentation to support findings.
• Develops detailed reports on each audit conducted.
• Reports include a review of findings and an identification of recommendation to correct any deficiencies and methods for improvement to processes.
• Conducts testing of corrective actions as identified.
• Conducts special audit studies for management, such as those required to discover controls for prevention of fraud.
• Prepares reports of finding and recommendations for management.
• Assists other auditors in completing their assignments as a means of maximizing audit efficiency and thus reducing lost time and involvement of corporate personnel.