RN Senior Medical Reviewer - CGS

Logistics

What You Will Do:

• 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 innerworkings 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.

To Qualify for This Position, You Will Need:

• Required License and Certificate: 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.

• Required Education: Associate Degree - Nursing, OR or Graduate of Accredited School of Nursing.

• Required Work Experience: Four years clinical, OR Two years clinical and two years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years.

• Required Skills: Working knowledge of managed care and various forms of health are 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.

• Required Software: Microsoft Office.

What We Prefer:

• Bachelor's degree- Nursing or Graduate of Accredited School of Nursing.

• Knowledge of database software.

• Knowledge of Medicare

• Proficient in Excel

• Team player

• Self-starter

What We Can Do for You:

• 401(k) retirement savings plan with company match.

• Subsidized health plans and free vision coverage.

• Life insurance.

• Paid annual leave – the longer you work here, the more you earn.

• Nine paid holidays.

• On-site cafeterias and fitness centers in major locations.

• Wellness programs and healthy lifestyle premium discount.

• Tuition assistance.

• Service recognition.

• Incentive Plan.

• Merit Plan.

• Continuing education funds for additional certifications and certification renewal.

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. Management will be conducting interviews with the most qualified candidates, with prioritization given to those candidates who demonstrate the preferred qualifications.

Equal Employment Opportunity Statement

BlueCross 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 mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 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. Here's more information.

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