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Senior Medical Reviewer
BlueCross BlueShield of South Carolina. Act as team lead for specialty programs, medical review, utilization management, and case management areas .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates strong clinical expertise and leadership in medical review and utilization management, ensuring quality healthcare services and compliance with established protocols. Proficient in communication, problem-solving, and workflow management to effectively support team operations and enhance service delivery.
Highest-signal resume keywords
Active RN LicensureClinical ExperienceMedical Review ExpertiseUtilization ManagementMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ExperienceMedical ReviewUtilization ManagementKnowledge of Healthcare Delivery SystemsAnalytical SkillsDecision-Making SkillsKnowledge of Criteria/Protocol SetsPresentation SkillsCustomer Service SkillsConfidential Information Handling
Soft Skills
Leadership SkillsOrganizational SkillsEffective CommunicationNegotiation SkillsJudgment Skills
Tools & Technologies
Microsoft OfficeWord Processing SoftwareSpreadsheet SoftwareDatabase Software
Certifications & Qualifications
Active RN LicensureCompact Multistate RN License
Industry Keywords
Managed CareHealthcare ServicesQuality ReviewsCompliance InitiativesHome Health
About the role
Key responsibilities & impact- Act as team lead for specialty programs, medical review, utilization management, and case management areas
- Provide assistance and support to the unit supervisor/manager
- Give direction, guidance, and training to staff
- Ensure appropriate levels of healthcare services are provided
- Function as a team leader/senior-level Medical Reviewer
- Maintain working knowledge of unit functions, department inner workings, and workflow
- Serve as a resource for staff and external entities by troubleshooting and resolving issues
- Keep the manager informed of problems and issues requiring resolution
- Assist management with monitoring workflow and workloads
- Reassign work and redirect work intake sources to balance workloads and meet timelines
- Monitor reporting and address aging issues
- Participate in departmental quality reviews and ensure adherence to the quality plan
- Give and receive feedback regarding medical review decision-making and technical claims processing issues
- Ensure quality work instructions, forms, and documents are developed or revised as needed
- Provide quality service and communicate effectively with internal and external customers
- Obtain information from internal departments, providers, government, and private agencies to resolve discrepancies and problems
- Participate in compliance initiatives, directed activities, and special projects as requested by management
- Work Monday-Friday, 40 hours per week, during 8:00am-4:30pm or 8:30am-5:00pm schedules
Requirements
What you’ll need- Associates in a job-related field
- Graduate of Accredited School of Nursing
- 4 years clinical experience, OR 2 years clinical and 2 years medical review/utilization review, OR a 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 including home health, rehabilitation, and/or broad medical surgical experience
- Knowledge of specific criteria/protocol sets and their use
- 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
- 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, and motivate others
- Microsoft Office proficiency
- Active, unrestricted RN licensure from the United States and the state of hire, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact, or active unrestricted specialty-area licensure/certification as required by the hiring division/area
- Preferred: knowledge of database software, Medicare regulations/policies/instructions/provisions, and home health and/or medical review system/processing procedures
- Preferred: working knowledge of Microsoft Excel, Access, or other spreadsheet/database software
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
- Opportunity to develop skills, advance careers, and contribute to company growth
- Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs