LPN Medical Reviewer I

Job title: LPN Medical Reviewer I

Company: BlueCross BlueShield Of South Carolina

Job description: Summary

Performs medical reviews using established criteria sets and/or performs utilization management of professional, inpatient or outpatient, facility benefits or services, and appeals. Documents decisions using indicated protocol sets or clinical guidelines. Provides support and review of medical claims and utilization practices.


What you will do:

Provide any of the following in support of medical claims review and utilization review practices:

Perform medical claim reviews and make a reasonable charge payment determination.

Monitor process’s timeliness in accordance with contractor standards.

Perform authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines.

Utilize allocated resources to back up review determination.

Review interdepartmental requests and medical information in a timely/effective manner in order to complete utilization process.

May conduct/perform high dollar forecasting research and formulate overall patient health summaries with future health prognosis and projected medical costs.

Perform screenings/assessments and determines risk via telephone.

Review/determine eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services.

Provide education to members and their families/caregivers.

Review first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each.

Conduct research necessary to make thorough/accurate basis for each determination made.

Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.

Respond accurately and timely with appropriate documentation to members and providers on all rendered determinations.

Participate in quality control activities in support of the corporate and team-based objectives.

Participate in all required training.

What you will need to qualify:

Required Licenses and Certificates:

  • Graduate of an Accredited School of Licensed Practical Nursing OR
  • Licensed Vocational Nursing.
  • Two years clinical experience.
  • Working knowledge of word processing software.
  • Good judgment skills.
  • Demonstrated customer service and organizational skills.
  • Demonstrated proficiency in spelling, punctuation, and grammar skills.
  • Analytical or critical thinking skills.
  • Ability to handle confidential or sensitive information with discretion.
  • Ability to remain in a stationary position and operate a computer.
  • Microsoft Office.
  • Active, unrestricted LPN/LVN licensure from the United States and in the state of hired, OR, active compact multistate unrestricted LPN license as defined by the Nurse Licensure Compact (NLC).

What We can Do for You:

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
  • Wellness program and healthy lifestyle premium discount
  • Tuition assistance
  • Service recognition
  • Employee Assistance
  • Discounts to movies, theaters, zoos, theme parks and more​

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure your meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. If the qualifications required proof of semester hours, please attach your transcript to your application.

Management will be conducting interviews with the most qualified candidates, with prioritization give to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail abilities@bcbssc.com or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

Expected salary:

Location: South Carolina

Job date: Sat, 06 Aug 2022 07:55:59 GMT

Click Here To Apply