Ourhrconnect

Ourhrconnect

Reviewer I, Medical

Myrtle Beach, South Carolina · Contract

No sponsorshipDetected 1 day ago
CybersecurityForecastingExcelLogisticsCustomer SupportResearchCommunicationCritical Thinking

About the role

  • Description Why should you join the BlueCross BlueShield of South Carolina family of companies?
  • We operate one of the most sophisticated data processing centers in the Southeast.
  • If you are dedicated to the same philosophy, consider joining our team!

Responsibilities

  • 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.
  • Performs screenings/assessments and determines risk via telephone.

Requirements

  • This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.
  • Bachelor's degree - Social Work, OR, Graduate of an Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing.
  • 2 years clinical experience.
  • Participates in all Required Licenses and Certificates.
  • Required Experience: 2 years clinical experience.
  • Required Skills and Abilities: Working knowledge of word processing software.
  • Required Software and Tools: Microsoft Office.

Nice to have

  • Associate Degree- Nursing OR Graduate of an Accredited School of Nursing.
  • Preferred Skills and Abilities: Working knowledge of spreadsheet and database software.
  • Preferred Software and Others Tools: Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.

Skills

  • Working knowledge of word processing software.
  • 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.
  • Working knowledge of spreadsheet and database software.
  • Demonstrated oral and written communication skills.
  • Ability to persuade, negotiate, or influence others.
  • Knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
  • Microsoft Office.

Compensation

  • This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.

Benefits

  • Subsidized health plans, dental and vision coverage
  • 401k retirement savings plan with company match
  • Life Insurance
  • Paid Time Off (PTO)
  • Education Assistance
  • 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.
  • Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.
  • 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.
  • 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.
  • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.

Equal opportunity

  • 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.

Visa & Work Authorization

  • This position requires the ability to obtain a security clearance, which requires applicants to be a U
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This listing is sourced directly from Ourhrconnect's careers page and normalized into a canonical job model.