Senior Medical Reviewer Jobs

Summary

Description

This position is open to remote candidates across the US. Preference will be given to candidates in Nashville, TN and Columbia SC. Candidates in these states will work on-site in a typical office environment.

What You’ll Do

• Maintain working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow.
• Function as team leader/senior-level Medical Reviewer.
• Participate/oversee special projects as requested by management.
• Follow process to ensure quality plan is adhered to and communicated to all parties.
• Obtain information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participate in departmental quality reviews.
• Give/receive feedback regarding medical review decision making and technical claims processing issues.
• Keep managers informed of any problems/issues that need resolving.
• Provide quality service and communicates effectively with external/internal customers in response to inquiries.
• Ensure that quality work instructions/forms/documents are developed/revised as needed.
• Provide leadership/guidance/direction/training to staff.
• Participate in compliance initiatives and other directed activities.
• Assist 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.
• Act as resource for staff/external entities troubleshooting as well as resolving issues.

To Qualify For This Position, You’ll Need

• Associate Degree - Nursing, OR 4-year degree in health-related field, OR Master's Degree in Occupational Therapy or Physical Therapy, OR, Master's in Social Work, Psychology, Counseling (for Div. 75 only) or Graduate of Accredited School of Nursing.
• A working knowledge of managed care and various forms of healthcare delivery systems.
• The ability to work independently, prioritize effectively, and make sound decisions.
• The ability to lead/direct/motivate others.
• Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
• Experience with Microsoft Office.
• The ability to handle confidential or sensitive information with discretion.
• 4 years clinical, OR, 2 years clinical and 2 years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years.
• 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.
• A working knowledge of word processing and spreadsheet software.
• Good judgment skills.
• The ability to persuade, negotiate, or influence others.
• Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills.
• Knowledge of specific criteria/protocol sets and the use of the same.
• Analytical or critical thinking skills.

We Prefer That You Have

• Knowledge of database software. Knowledge of Medicare regulations/policies/instructions/provisions.
• Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
• Bachelor's degree in Nursing or Graduate of Accredited School of Nursing.
• Knowledge of home health, and/or system/processing procedures for medical review.

What Blue Can Do For You

Our comprehensive benefits package includes:

• Paid annual leave — the longer you work here, the more you earn
• 401(k) retirement savings plan with company match
• Service recognition
• Subsidized health plans and free vision coverage
• On-site cafeterias and fitness centers in major locations
• Life insurance
• Nine paid holidays
• Wellness programs and a healthy lifestyle premium discount
• Tuition assistance

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 our recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [email protected] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.