Reviewer I, Medical
Not Disclosed•Full-TimeOn-site
location_on806, Villarosa Drive, Cipriana Park, Myrtle Beach, Horry County, South Carolina, 29572, United States
About the Team
BlueCross BlueShield of South Carolina has been a cornerstone of the national landscape for over seven decades, with roots deeply embedded in the South Carolina community. As the largest insurance company in the state, we are also one of the nation's leading administrators of government contracts and operate one of the most sophisticated data processing centers in the Southeast. Through our diverse family of subsidiary companies, including PGBA, we build on various business strengths to deliver outstanding service to our customers.
About the Role
This position serves as a critical link in our utilization management and medical review operations. You will perform medical reviews using established criteria sets for professional, inpatient, or outpatient facility benefits and services. Your work involves documenting decisions based on clinical guidelines, supporting the review of medical claims, and managing appeals. The role requires a blend of clinical judgment and administrative precision to ensure appropriate coverage and medical necessity.
You will be part of a team dedicated to a philosophy of service and community impact. The role involves conducting screenings, determining risk levels, and providing education to members and caregivers. You will also participate in quality control activities and may be tasked with high-dollar forecasting research to formulate patient health summaries and projected medical costs.
Hiring Process
After submitting your application, our recruiting team will review your resume to ensure you meet the qualifications. This process may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements.
Location and Logistics
This is an onsite position located at 8733 Highway 17 Bypass, Myrtle Beach, S.C., 29575. The standard hours are 8:00 am to 5:00 pm, Monday through Friday. Please note that this position will transition to remote work after 6 months of onsite training.
Important Requirements
This position requires the ability to obtain a security clearance, which necessitates that applicants be U.S. Citizens. Additionally, as a Service Contract Act (SCA) employee, you are required to enroll in our health insurance plan, even if you already have other coverage. Supplemental pay for health coverage is provided until enrollment is complete.
Equal Opportunity
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment. We promote 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. As a federal contractor, we maintain affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans.
We are committed to providing reasonable accommodations to individuals with disabilities, pregnant individuals, and those needing accommodations for sincerely held religious beliefs. If you need special assistance or an accommodation while seeking employment, please contact mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480.
Work location
Work model: On-site
806, Villarosa Drive, Cipriana Park, Myrtle Beach, Horry County, South Carolina, 29572, United States
Myrtle Beach, South Carolina
Key Responsibilities
- check_circleConduct risk assessments and screenings via telephone
- check_circleEducate internal and external staff on medical reviews and coding procedures
- check_circleRespond to members and providers with accurate documentation of determinations
- check_circleParticipate in quality control activities to support corporate objectives
- check_circlePerform medical claim reviews and determine reasonable charge payments
- check_circleReview and determine eligibility, benefit levels, and medical necessity of services
- check_circlePerform high-dollar forecasting research and formulate patient health summaries
- check_circleManage the authorization process to ensure coverage aligns with guidelines
- check_circleConduct utilization management for professional, inpatient, and outpatient services
- check_circleReview first-level appeals and document determination bases thoroughly
Requirements
- verifiedBachelor's degree in Social Work OR graduate of Accredited School of LPN/LVN
- verified2 years clinical experience
- verifiedActive unrestricted LPN/LVN licensure in state of hire OR active compact multistate LPN license OR active unrestricted LBSW licensure
- verifiedAbility to obtain security clearance
- verifiedU.S. Citizen
- verifiedWorking knowledge of Microsoft Office
Nice to Have
Associate Degree in Nursing or Graduate of an Accredited School of Nursing. Working knowledge of spreadsheet and database software. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Knowledge of Microsoft Excel, Access, or other spreadsheet/database software. 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 & Perks
check_circleSubsidized health plans, dental and vision coveragecheck_circle401k retirement savings plan with company matchcheck_circleLife Insurancecheck_circlePaid Time Off (PTO)check_circleOn-site cafeterias and fitness centers in major locationscheck_circleEducation Assistancecheck_circleService Recognitioncheck_circleNational discounts to movies, theaters, zoos, theme parks and more
Similar Job Opportunities
Skills, education and keywords
Skills: Microsoft Office, Microsoft Excel, Microsoft Access, LPN, LVN, LBSW, RN, Nurse Licensure Compact, Medical Terminology, Coding Procedures.
Education: Bachelor's degree in Social Work required; Associate Degree in Nursing preferred.
Frequently asked questions about Reviewer I, Medical at BlueCross BlueShield of South Carolina
What does a Reviewer I, Medical at BlueCross BlueShield of South Carolina do?expand_more
Day-to-day, the Reviewer I, Medical at BlueCross BlueShield of South Carolina will conduct risk assessments and screenings via telephone; educate internal and external staff on medical reviews and coding procedures; respond to members and providers with accurate documentation of determinations; and participate in quality control activities to support corporate objectives.
What are the requirements for this Reviewer I, Medical role?expand_more
BlueCross BlueShield of South Carolina is looking for candidates who meet the following requirements: Bachelor's degree in Social Work OR graduate of Accredited School of LPN/LVN; 2 years clinical experience; Active unrestricted LPN/LVN licensure in state of hire OR active compact multistate LPN license OR active unrestricted LBSW licensure; Ability to obtain security clearance; U.S. Citizen; and Working knowledge of Microsoft Office.
Where is the Reviewer I, Medical role at BlueCross BlueShield of South Carolina located?expand_more
Reviewer I, Medical at BlueCross BlueShield of South Carolina is based in 806, Villarosa Drive, Cipriana Park, Myrtle Beach, Horry County, South Carolina, 29572, United States. This is a on-site role.
Is this Reviewer I, Medical job remote, hybrid, or on-site?expand_more
BlueCross BlueShield of South Carolina has listed this Reviewer I, Medical role as on-site.
How much experience is required for this Reviewer I, Medical role?expand_more
Reviewer I, Medical at BlueCross BlueShield of South Carolina typically requires 2+ years of relevant experience at the mid level level.
What skills do you need for the Reviewer I, Medical role at BlueCross BlueShield of South Carolina?expand_more
Key skills for Reviewer I, Medical at BlueCross BlueShield of South Carolina include Microsoft Office; Microsoft Excel; Microsoft Access; LPN; LVN; LBSW; RN; and Nurse Licensure Compact.
What education is required for Reviewer I, Medical at BlueCross BlueShield of South Carolina?expand_more
Educational requirements for this role: Bachelor's degree in Social Work required; and Associate Degree in Nursing preferred.
What category does the Reviewer I, Medical role belong to?expand_more
Reviewer I, Medical at BlueCross BlueShield of South Carolina is part of the scientific & qa job category on Recrutus.
About BlueCross BlueShield of South Carolina
BlueCross BlueShield of South Carolina, headquartered in Columbia, South Carolina, operates as a major insurance provider within the state and the nation. For over sixty years, the organization has maintained a strong local presence while serving as a significant part of the national insurance landscape. As the largest insurance company in South Carolina, it holds a unique distinction of being the only entity in the state with an A+ Superior A.M. Best rating. The company also functions as a prominent administrator for government contracts and utilizes one of the most advanced data processing centers in the Southeast, supported by a diverse family of subsidiary companies.
The organization is an independent licensee of the Blue Cross and Blue Shield Association and operates with a commitment to community support. Employees frequently engage with dozens of nonprofit organizations annually, reflecting a culture of giving. The company offers a comprehensive benefits package including a 401(k) with a match, subsidized health and vision plans, life insurance, paid leave, wellness programs, and education assistance. Specific provisions exist for National Guard and Reserve members, covering pay differences during active duty.
BlueCross BlueShield of South Carolina is an Equal Opportunity Employer that considers all qualified applicants 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.
Browse more roles: All BlueCross BlueShield of South Carolina jobs, scientific & qa jobs on Recrutus.