Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior), making us the only health insurance company in South Carolina with that rating. We’re the largest insurance company in South Carolina …and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allow us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Job Title: Reviewer II, Medical

Position Details:

• MAX HOURLY PAY RATE: $25.00/HOUR.
• Work Schedule/Hours: 8 hours per day, 3 days per week (Candidate can select days M-F).
• 100% Onsite.
• CONTRACT TO HIRE.
• INTERVIEW PROCESS: IN PERSON.
• License/Certification required: Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nure Licensure Compact (NLC).
• 4-6 weeks onsite training.

Top 2-4 PREFERRED/NICE TO HAVE skill sets/qualities:

• Hospital/doctor’s office experience.
• Medical review.    
• Microsoft Office Skills.

Duties:

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines. 
• Documents decisions using indicated protocol sets or clinical guidelines. 
• Provides support and review of medical claims and utilization practices.
• 70% Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.
• 20% Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.
• 10% Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management. 

Required Skills and Abilities: 

• Required Education: Associate degree - Nursing or Graduate of an accredited School of Nursing. 
• Required Work Experience: 2 years clinical experience. 
• Required Training: Active RN licensure in state hired, OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). 
• Working knowledge of word processing software. 
• Ability to work independently, prioritize effectively, and make sound decisions. 
• Good judgment skills. Demonstrated customer service and organizational skills. 
• Demonstrated oral and written communication skills. Analytical or critical thinking skills. 
• Ability to handle confidential or sensitive information with discretion. 
• Required Software and Tools: Microsoft Office. 

Pay Transparency:

• This is the pay range that Magnit reasonably expects to pay someone for this position is $21.00/hour - $25.00/hour W-2.
• Benefits: Medical, Dental, Vision, 401K (provided minimum eligibility hours are met).

BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found dedication, work ethics and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more.

Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. If you're ready to join a diverse company with secure, community roots and an innovative future, apply for a position now!