Medical Reviewer

Medical Reviewer PositionJoin our team serving active and retired US military members and their covered family members. We strive to ensure that these dedicated individuals and their loved ones receive high-quality care administered as economically as possible and in accordance with current evidence-based care guidelines. As part of our expanding team of medical reviewers, you will evaluate the medical records to determine medical necessity and perform utilization management of professional, inpatient, outpatient facility benefits or services and appeals. You will document decisions using indicated protocol sets, or clinical guidelines and provide support and review of medical claims and utilization practices.In addition to being able to serve those who protect our country, you won't have the physical stress of working in a direct care setting and you will have nights, weekends, and holidays off to spend with those you love. For those wanting to grow their career with us, we offer tuition reimbursement, skills training classes, an aspiring leaders' program, and promotional opportunities throughout our family of companies. In these uncertain times, we are a solid company who has served individuals, businesses, associations, and the US government for over 70 years. Our leadership is committed to ensuring that we will be serving our customers for another 70 years.Position Purpose: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.Logistics:PGBA - one of BlueCross BlueShield of South Carolina's subsidiary companies.Location:This is an onsite position located at 8733 Highway 17 Bypass, Myrtle Beach, S.C., 29575. The hours are 8:00am - 5pm, Monday through Friday. This position will be remote after 6 months of onsite training.Government Clearance:This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.SCA Benefit Requirements:BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). As a Service Contract Act (SCA) employee, you are required to enroll in our health insurance, even if you already have other health insurance. Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment.What You Will Do: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. Participates in all Required Licenses and Certificates.To Qualify for This Position, You Will Need:Required Education: Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.Required Experience: 2 years clinical experience.Required Skills and Abilities: 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.Required Software and Tools: Microsoft Office.Required Licenses and Certificates: Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, 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.Our Comprehensive Benefits Package Includes The Following:Subsidized health plans, dental and vision coverage401k retirement savings plan with company matchLife InsurancePaid Time Off (PTO)On-site cafeterias and fitness centers in major locationsEducation AssistanceService RecognitionNational discounts to movies, theaters, zoos, theme parks and moreWhat We Can Do for You:We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.What to Expect Next:After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.Equal Employment Opportunity StatementBlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.If you need special assistance or an accommodation while seeking employment, please email View email address on click.appcast.io or call View phone number on click.appcast.io with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. 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