Job Description

Internal Reference Number: R1044044
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.Description

Location

This position is full-time (40 hours/week) Monday-Friday from 8:00 am - 4:30 pm ET , and will work from home after 6 months of on-site training and once production goals and quality checks are met .

• Due to TRICARE security access requirements for this position, the selected candidate must be a U.S. citizen, complete a Department of Defense SF85 or SF86 form via the electronic system eAPP, Declaration for Federal Employment Form OF 306 and submit two fingerprint cards. The U.S. government will be completing a thorough background investigation on the candidate selected for this position.

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 of 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.

What We Prefer You Have:

• Preferred Education: Associate Degree- Nursing OR Graduate of an Accredited School of Nursing.
• Preferred Skills and Abilities: Working knowledge of spreadsheet and database software. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others.
• Preferred Software and Other Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
• Preferred Licenses and Certificates: 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).

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage

• 401k retirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• Education Assistance

• Service Recognition

• National discounts to movies, theaters, zoos, theme parks and more

What 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 our recruiter to verify resume specifics and salary requirements.

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 disabilitiesand 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.comor 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 moreinformation.

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