Senior Medical Reviewer (Behavioral Health Focused)

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

11d•Remote

About The Position

We are currently hiring for a Senior Medical Reviewer to join BlueCross BlueShield of South Carolina. In this role as a Senior Medical Reviewer, you will act as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff and ensure appropriate levels of healthcare services are provided. This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote in SC. Our ideal candidate must reside in South Carolina and may be required to report on-site occasionally, and will oversee member-facing patient visits by team members within SC.

Requirements

Associates in a job-related field
Graduate of Accredited School of Nursing
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.
Working knowledge of managed care and various forms of health care 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.
Microsoft Office.
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.

Nice To Haves

Four years of recent clinical experience in a defined Behavioral Health specialty area. Specialty areas include: Serious Mental Illness (SMI), Trauma and Post-Traumatic Stress Disorder, Substance Use Disorders (SUD), Child and Adolescent Behavioral Health, and Cognitive Disorders. Or, 4 years of Behavioral Health utilization review/case management/clinical/or combination; 2 of the 4 years must be clinical.
4 years of Behavioral Health clinical experience as RN, LISW-CP, LMSW, or LPC.
Experience with care coordination and case management process for High-Risk and Intensive Case Management levels of Behavioral Health.
Knowledge of Managed Care regulations/policies/instructions/provisions.
Experience with South Carolina Behavioral Health resources related to supports/services and referral linkage.
Working knowledge of Microsoft Teams, Word, PowerPoint OneNote, Excel, Outlook, Tableau, OR other spreadsheet/database software.
Bachelor's degree- Nursing or Graduate of Accredited School of Nursing.
Knowledge of database software.
Knowledge of Medicare regulations/policies/instructions/provisions.
Knowledge of home health, and/or system/processing procedures for medical review.

Responsibilities

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 interworkings 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.