Reviewer I, Medical

Summary 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. Position Purpose Conducts medical and utilization reviews, determines coverage and payment, and supports the claims and utilization processes for BlueCross BlueShield of South Carolina and its subsidiary, PGBA. Responsibilities Perform medical claim reviews and determine reasonable charge payments. Monitor process timeliness in accordance with contractor standards. Conduct authorization processes to ensure coverage aligns with benefit and medical necessity guidelines. Utilize allocated resources to support review determinations. Review interdepartmental requests and medical information timely and effectively. Perform high‑dollar forecasting research and develop patient health summaries, future health prognosis, and projected medical costs. Screen and assess risk via telephone while determining eligibility, level of benefits, and medical necessity of services. Provide education to members and their families/caregivers about coverage determinations. Review first‑level appeals and ensure thorough documentation of each determination and basis. Conduct research to support accurate and thorough determination bases. Educate internal/external staff regarding medical reviews, terminology, coverage determinations, and coding procedures. Respond accurately and timely with appropriate documentation to members and providers. Participate in quality control activities to support corporate and team objectives. Qualifications Education: Bachelor’s degree in Social Work, Graduation from an accredited Licensed Practical Nursing or Licensed Vocational Nursing school, or active LBSW licensure. Experience: Minimum 2 years of clinical experience. Skills & Abilities: Word processing proficiency, good judgment, customer service, organizational, spelling/punctuation, analytical or critical thinking, confidentiality handling, stationary computer operation. Software & Tools: Microsoft Office (Word, Excel, Outlook). Licenses & Certifications: Active, unrestricted LPN/LVN, or active RN (or compact multistate equivalents), or active LBSW licensure where applicable. Benefits Health, dental, and vision coverage (subsidized). 401(k) retirement savings plan with company match. Life insurance. Paid Time Off (PTO). On‑site cafeterias and fitness centers. Education assistance and service recognition programs. National discounts to movies, theaters, zoos, theme parks, and more. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and its subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote opportunities for all persons. We comply with applicable federal, state, and local laws and regulations and provide reasonable accommodations to individuals with disabilities, pregnant individuals, and others, as required. We use E‑Verify, comply with Pay Transparency, and are an Equal Opportunity Employer. #J-18808-Ljbffr 001 BlueCross and BlueShield of South Carolina