South Carolina’s largest and oldest health insurance company
Senior Medical Reviewer
Location
South Carolina
Posted
11 days ago
Salary
0
Seniority
Senior
Job Description
Senior Medical Reviewer
BlueCross BlueShield of South Carolina
• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas. • Provides leadership/guidance/direction/training to staff. • Maintains a working knowledge of unit functions and the ability to interpret to new hires. • Acts as a 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. • Participates in departmental quality reviews. • Gives/receives feedback regarding medical review decision making and technical claims processing issues. • Participates in compliance initiatives and other directed activities. • Participates/oversees special projects as requested by management.
Job Requirements
- Associate Degree - Nursing OR Graduate of Accredited School of Nursing.
- Four years of clinical experience, OR Two years of clinical and two years of medical review/utilization review, OR Combination of health plan, clinical, and business experience totaling four years.
- Preferred: ESRD/renal dialysis experience, Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting, Three or more years’ education/training/consulting experience related to Dialysis services, Three or more years’ experience in quality management coordination related to Dialysis services.
- Working knowledge of managed care and various forms of healthcare 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.
- 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.
Benefits
- Health insurance
- Retirement plans
- Paid time off
- Flexible work arrangements
- Professional development
Related Guides
Related Categories
Related Job Pages
More Medical Reviewer Jobs
Physician, Medical Case Reviewer
Simsy VenturesA builder, an institutional co-founder & a partner from ideas to new startups, ventures & beyond 🚀
• Conduct objective medical case reviews using standardized assessment criteria • Evaluate the timeliness and appropriateness of care provided • Identify quality improvement opportunities • Review cases initiated for non-standardized performance improvement reasons • Assess medical decision-making and compliance with best practices • Provide expert medical opinions • Analyze complex clinical scenarios from an impartial, evidence-based perspective
Medical Reviewer
Cohere HealthCohere Health is a Software-as-a-Service (SaaS) company focused on improving the patient journey by enhancing the quality of care at lower costs, as well as emp
Role Description We are looking for an orthopedic spine Physician Assistant to help deliver on Cohere’s musculoskeletal and orthopedic programs by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. The physician assistant should have previous experience in managing spine conditions in an office setting as well as assisting on spine cases in the operating room. This is a remote-first role that may require travel to Boston, MA for new hire onboarding and occasional in-person team meetings and company events. What you’ll do: - Provide timely medical reviews that meet Cohere’s stringent quality parameters - Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen - Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision - Use correct templates for documenting decisions during case review - Meet the appropriate turn-around times for clinical reviews - Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers - Support projects specific to building the team's clinical expertise and efficiency, as delegated - Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated - Clearly communicate with team members Qualifications - Graduate of an accredited Physician Assistant program - Current NCCPA certification (PA-C) and active, unrestricted Physician Assistant license in at least one U.S. state - 3+ years of clinical experience supporting orthopedic spine surgeons and/or neurosurgeons treating spine conditions - Utilization management, prior authorization, or medical review experience a plus - Membership in organizations such as the AAPA or specialty spine organizations Benefits - Fully remote opportunity with about 5% travel - Medical, dental, vision, life, disability insurance, and Employee Assistance Program - 401K retirement plan with company match; flexible spending and health savings account - Flex Time Off + company holidays - Up to 14 weeks of paid parental leave - Pet insurance The salary range for this position is $120,000 to $135,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. Interview Process - Connect with Talent Acquisition for a Preliminary Phone Screening - Meet your Hiring Manager! - Behavioral Interview(s) Company Description Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum–including policy, prior authorization, payment accuracy, and more–the company improves collaboration and reduces burden, resulting in up to 8x ROI and 94% provider satisfaction. Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone. We can’t wait to learn more about you and meet you at Cohere Health! Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.
Board Certified Disability Peer Physician Reviewer – Medical Oncology
Dane StreetNational Provider of IME and Medical Peer Review Services
• Evaluate and review disability claims • Conduct reviews from the convenience of home • Participate in a flexible scheduling environment
Medical Advisory Reviewer – Orthopedic Surgery
Dane StreetNational Provider of IME and Medical Peer Review Services
- Apply your expertise to conduct comprehensive reviews of clinical cases - Provide objective, evidence-based medical opinions - Review medical records and prepare clear and concise clinical summaries - Respond to specific questions from clients related to Orthopedic Surgery care



