Physician Advisor

BlueCross BlueShield of South Carolina

. Optimize efficient management of resources and ensure patients are in the appropriate level of care .

Posted 10/9/2026full-timeRemote • United StatesSeniorLead💰 $176,132 - $355,017 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity assessment, utilization management, and compliance with CMS and MCG guidelines. Proficient in collaborating with multidisciplinary teams to enhance care management and optimize patient services.

Highest-signal resume keywords

Medical Doctor (MD) Or Osteopathic Doctor (DO)Utilization ManagementMedical Necessity AssessmentCompliance With CMS And MCG GuidelinesExcellent Verbal And Written Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Data AnalysisCoding ImprovementsQuality Improvement ActivitiesPre-Admission ReviewsProcedure PrecertificationEmergency Room Case ManagementPopulation Based Disease ManagementPublic Health InitiativesPrior Authorization Review

Soft Skills

Excellent JudgmentOrganizational SkillsCustomer Service SkillsPresentation SkillsAnalytical Or Critical Thinking SkillsPersuasion And Negotiation Skills

Tools & Technologies

Microsoft Office

Certifications & Qualifications

Current Board Certification In A Recognized SpecialtyActive, Unrestricted Medical License

Industry Keywords

Healthcare ComplianceQuality ProgramsNCQAMedical ManagementManaged CareEvidence-Based CarePHI ProtectionAccreditation Standards

About the role

Key responsibilities & impact

Optimize efficient management of resources and ensure patients are in the appropriate level of care
Support documentation, coding improvements, compliance, and appropriate use of diagnostic and therapeutic modalities
Provide assessment and determination of medical necessity in case evaluation and utilization management
Collaborate with multidisciplinary teams to implement care management protocols and optimize services
Communicate with hospital physicians, care coordination, and utilization management staff regarding evidence-based care and documentation
Perform pre-admission, continued stay, procedure precertification, post-service, emergency room, and individual case management reviews
Respond to clinical review assistance requests from Case Management
Apply CMS and MCG evidence-based guidelines and maintain regulatory, accreditation, and payer-policy compliance
Protect and disclose PHI according to HIPAA standards
Serve as a medical resource for quality improvement and liaison to the medical community
Advise and educate providers and internal staff on medical policies, utilization specifications, coding, and medical necessity
Research new or controversial medical procedures and technologies to recommend policy, coverage, utilization, and coding criteria
Participate in medical review policy, quality programs, and inter-reviewer reliability studies

Requirements

What you’ll need

Medical Doctor (MD) or Osteopathic Doctor (DO) with current license to practice
8 years-broad clinical experience to include knowledge of utilization and medical review; experience may include paid training
Active, unrestricted medical license from the United States and in the state of hire
Current board certification in a recognized specialty
Demonstrated ability to direct multiple strategic projects
Excellent verbal and written communication skills
Excellent judgment, organizational, customer service, and presentation skills
Excellent analytical or critical thinking skills
Knowledge of strategic concepts
Ability to persuade, negotiate, or influence others
Microsoft Office
Sponsorship is not eligible now or in the future
Preferred: experience with prior authorization review
Preferred: 2 years medical data analysis/analytical capability to interpret statistical information
Preferred: experience with medical oversight of quality improvement activities
Preferred: experience with quality committees or NCQA
Preferred: experience with population based disease management or public health initiatives
Preferred: experience in medical management or managed care
Preferred: demonstrated understanding of Medicare programs

Benefits

Comp & perks

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