Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote. Our ideal candidate must reside in South Carolina and may be required to conduct occasional member-facing patient visits within SC. What You’ll Do: 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. To Qualify for This Position, You'll Need the Following: Required Education: Associates in a job-related field Degree Equivalency: Graduate of Accredited School of Nursing Required Work Experience: 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. Required Skills and Abilities: 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. Required Software and Tools: Microsoft Office. Required Licenses and Certificates: 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. We Prefer That You Have the Following: Must have experience of working directly with individuals with mental illnesses. Preferred Education: Bachelor's degree- Nursing or Graduate of Accredited School of Nursing. Preferred Skills and Abilities: Knowledge of database software. Knowledge of Medicare regulations/policies/instructions/provisions. Knowledge of home health, and/or system/processing procedures for medical review. Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment. 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 What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information . Some states have required notifications. Here's more information .

• Prior authorization review of physical and behavioral health related services • Utilization of clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program • Application of critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for members with disabilities and special healthcare needs • Taking provider calls related to prior authorization questions and making calls to members to inform of the coverage determination • Gathering clinical information and applying appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment, in order to render coverage determination/recommendation/discharge planning along the continuum of care • Utilization of clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members • Identification of members who may benefit from care management programs and facilitation of the referral • Identification of opportunities to promote quality effectiveness of healthcare services and benefit utilization • Sedentary work involving periods of sitting, talking, and listening • Performing other duties as assigned

Dane Street wants you to join our dynamic team of expert reviewers! In this role, you will have the opportunity to utilize your medical expertise to conduct thorough reviews of clinical cases. This telework opportunity allows you to customize your schedule as a 1099 independent contractor. Your main task will be to evaluate medical records, provide clinical summaries, engage in peer communications, and answer specific questions posed by our clients. We are on the lookout for talented professionals in the following area: - OB/GYN-Obstetrics and Gynecology Be a part of a team that values your skills and dedication to improving patient care. Your expertise is vital to helping us deliver high-quality healthcare assessments.

Dane Street wants you to join our dynamic team of expert reviewers! In this role, you will have the opportunity to utilize your medical expertise to conduct thorough reviews of clinical cases. This telework opportunity allows you to customize your schedule as a 1099 independent contractor. Your main task will be to evaluate medical records, provide clinical summaries, engage in peer communications, and answer specific questions posed by our clients. We are on the lookout for talented professionals in the following area: - Reproductive Endocrinology/Infertility Be a part of a team that values your skills and dedication to improving patient care. Your expertise is vital to helping us deliver high-quality healthcare assessments.