Senior Medical Reviewer
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Job Description
Team Lead for specialty programs, providing guidance and support to medical review staff. Overseeing quality assurance and compliance initiatives at Palmetto GBA, a BlueCross BlueShield subsidiary.
Responsibilities:
- 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 inner workings 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 work loads), 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.
Requirements:
- Associate Degree - Nursing, OR Graduate of Accredited School of Nursing.
- Four years clinical, OR Two years clinical and two years medical review/utilization review, OR Combination of health plan, clinical, and business experience totaling four years.
- Working knowledge of managed care and various forms of health are 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.
- Microsoft Office.
- 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.
Benefits:
- 401(k) retirement savings plan with company match.
- Subsidized health plans and free vision coverage.
- Life insurance.
- Paid annual leave – the longer you work here, the more you earn.
- Nine paid holidays.
- On-site cafeterias and fitness centers in major locations.
- Wellness programs and healthy lifestyle premium discount.
- Tuition assistance.
- Service recognition.
- Incentive Plan.
- Merit Plan.
- Continuing education funds for additional certifications and certification renewal.
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