medical-reviewer

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state. We are the largest insurance company in South Carolina. We are also the only one that has an A+ Superior A.M. Best rating. We are one of the nation's leading government contract administrators. We operate one of the most sophisticated data processing centers in the Southeast and have a diverse family of subsidiary companies.

Our full-time employees enjoy benefits like a 401(k) retirement savings plan with company match, subsidized health plans, free vision coverage, life insurance, paid annual leave and holidays, wellness programs and education assistance. If you are a full-time employee in the National Guard or reserves, we will cover the difference in your pay if you are called to active duty. BlueCross has a dedicated corporate culture of community support. Our employees are some of the most giving in the country. They support dozens of nonprofit organizations every year.

If you're ready to join a diverse company with secure, community roots and an innovative future, apply for a position now! 

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. We are an Equal Opportunity/Affirmative Action Employer. We will consider all qualified applicants for employment regardless of age, race, color, national origin, gender, religion, veteran status, disability, weight, gender orientation, gender identity, genetic information or any other legally protected status.

BlueCross BlueShield of South Carolina

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations.
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines.
• Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement.
• Monitors process’s timeliness in accordance with contractor standards.
• Documents medical rationale to justify payment or denial of services and/or supplies.
• Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines.
• Participates in quality control activities in support of the corporate and team-based objectives.
• Provides guidance, direction, and input as needed to LPN team members.
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback.
• Assists with special projects and specialty duties/responsibilities as assigned by management.

Medical Reviewer II – Prior-Auth A/B MAC

Medical Reviewer II performing medical reviews utilizing clinical information and established guidelines. Supporting insurance claims management and educating staff regarding processes and terminology.

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines
• Documents decisions using indicated protocol sets or clinical guidelines
• Provides support and review of medical claims and utilization practices
• Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines
• Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement
• Monitors process’s timeliness in accordance with contractor standards
• Documents medical rationale to justify payment or denial of services and/or supplies
• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines
• Participates in quality control activities in support of the corporate and team-based objectives
• Provides guidance, direction, and input as needed to LPN team members
• Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback

RN Medical Reviewer II

Medical Reviewer conducting medical claims reviews for BlueCross BlueShield of South Carolina. Working onsite initially then transitioning to remote after training period.

Greenlife Healthcare Staffing is a New York based healthcare recruitment agency specializing in permanent hires and locum tenens. We match physicians and advanced practitioners to hospitals, clinics, nursing homes, multi-specialty groups, and private practices. 

In today's competitive economy, many healthcare organizations are faced with reducing operating costs, while still providing top-level care to its patients. Finding the physicians you need to grow and preserve your healthcare organization has never been more challenging. We collaborate closely with our clients to understand their existing performance, current circumstances, and reduce cost expenditures associated with the current healthcare environment.

Integrity, honesty, and transparency are the principles we stand by. We recognize our responsibility to influence careers and lives through our insight, advice, and solutions.

Visit our website at www.glhstaffing.com to learn more about how Greenlife can serve you. We look forward to working with you!


Greenlife Healthcare Staffing

• Conduct reviews up to and including the appeal level. This includes chart screen, compiling regulatory guidance, researching insurer requirements, completing electronic worksheets, and preparing final determinations.
• Act as a resource for the administrative and clinical staff in training, problem-solving, and clarifying determinations. Will provide technical assistance and conduct/participate in staff huddles.
• Participate in collaborative training
• Other activities as may be deemed necessary

RN Clinical Reviewer – IDR

Registered Nurse Clinical Reviewer performing medical-legal reviews and appeals at Greenlife Healthcare Staffing. Hybrid role requiring both remote and office-based tasks in New York.

• Performs medical claim reviews and makes a reasonable charge payment determination
• Monitors process's timeliness in accordance with contractor standards
• Performs authorization process, ensuring coverage for appropriate medical services within benefit and medical necessity guidelines
• Utilizes allocated resources to back up review determination
• Reviews 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
• Performs screenings/assessments and determines risk via telephone
• Reviews/determines eligibility, level of benefits, and medical necessity of services and/or reasonableness and necessity of services
• Provides education to members and their families/caregivers
• Reviews first level appeal and ensures utilization or claim review provides thorough documentation of each determination and basis for each
• Conducts 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
• Responds accurately and timely with appropriate documentation to members and providers on all rendered determinations
• Participates in quality control activities in support of the corporate and team-based objectives
• Participates in all Required Licenses and Certificates

LPN Medical Reviewer I-2

Performs medical reviews and utilization management of facility benefits at BlueCross BlueShield. Responsible for documentation and support of medical claims and utilization practices.

Connecticut Children's is a leading pediatric healthcare provider dedicated to transforming children's health and well-being. With over 40 locations across Connecticut, Western Massachusetts, and Eastern New York, it offers a comprehensive range of specialty care services, including prenatal care, pediatric surgery, and mental health support tailored specifically for children and adolescents. The organization is committed to addressing both the physical and emotional needs of children, while also engaging in research and community initiatives to promote overall health and wellness.

Connecticut Children’s is a leading pediatric academic medical center consistently ranked by our peers as among the best children’s hospitals in the nation. Connecticut Children’s is the only hospital in Connecticut dedicated exclusively to the health and well-being of children and families.

Connecticut Children’s physicians and researchers are dedicated to advancing pediatric care through medical innovation, cutting-edge technology, and research. With more than 200 physicians and 200 pediatric residents and fellows in over 20 pediatric specialty areas, Connecticut Children’s serves as the primary teaching, clinical and research site for the University of Connecticut School of Medicine.

For more information, visit www.connecticutchildrens.org or connect with us on Facebook at www.facebook.com/connecticutchildrens and Twitter at www.twitter.com/ctchildrens.

Connecticut Children's

• Collect and submit reliable and accurate data to the ACS NSQIP.
• Conduct high-quality data compilation, documentation and entry into the ACS NSQIP database of all eligible surgeries for the hospital.
• Work closely with surgeons and other clinical personnel to identify opportunities for clinical quality improvement.
• Manage special projects with populations from neonates through adolescents and apply them to clinical practice.

Surgical Clinical Reviewer

Surgical Clinical Reviewer at Connecticut Children’s responsible for collecting and submitting surgery data to ACS NSQIP while collaborating with clinical staff.

“In everything we do, we set the highest standards for quality and competence on every project. As a result, our actions become the benchmark for our industry but also our own guiding principle, which we renew every day”.

DQS sets the highest standards of expertise, experience, and quality for its customers. DQS core competencies lie in the performance of certification audits and assessments. This makes DQS, headquartered in Frankfurt am Main/Germany with an annual turnover of 136 Mio EUR (in 2020) one of the leading providers worldwide with the claim to set new benchmarks in reliability, quality, and customer orientation at all times. Over 2,500 highly qualified and experienced auditors carry out over 125,000 customer-specific audits according to over 200 recognized norms and standards in more than 60 countries every year. 

DQS was founded more than 35 years ago by the German Society for Quality (DGQ), the German Institute for Standardization (DIN) and other German industry associations with the claim to perform certifications and audits for organizations worldwide at the highest level. With its foundation, DQS was the first independent certification service provider in Germany. In 2008, the U.S. organization Underwriters Laboratories brought its international management system certification business into the group as a further shareholder, thus enabling the group to take a major step towards a global presence.

• fachliche Prüfung und Bewertung von Bewertungen und Gutachten zu Medizinprodukten im Rahmen der geltenden regulatorischen Anforderungen gemäß MDR (EU-Verordnung 2017/745)
• mit Kolleginnen und Kollegen aus verschiedenen Fachbereichen zusammenarbeiten, um sicherzustellen, dass die Bewertungen medizinisch fundiert, nachvollziehbar und regelkonform sind
• feststellen, wann ein Fachbeitrag zur Beurteilung der vom Hersteller durchgeführten klinischen Bewertung erforderlich ist, und entsprechend qualifizierte klinische Experten benennen
• Schulung der externen klinischen Sachverständigen in den Anforderungen der Verordnung (EU) 2017/745, Leitlinien und Normen sowie Sicherstellen ihres Bewusstseins über Bedeutung und Auswirkungen ihrer Bewertungen und Empfehlungen
• Überprüfung der Vergleichbarkeit und Konsistenz der Bewertungen der klinischen Sachverständigen
• Bewertung der klinischen Bewertung des Herstellers und des Gutachtens externer Sachverständiger sowie Abgabe einer Empfehlung für die Zertifizierungsentscheidung
• Durchführung der klinischen Bewertung und Erstellung des Bewertungsberichts (CEAR)

Interner Kliniker, Clinical Reviewer

Clinical Reviewer assessing medical product evaluations under MDR regulations. Collaborating with experts to ensure compliance and quality in assessments.

Christian Care Ministry is an organization that offers a healthcare sharing program called Medi-Share, which is an affordable and faith-based alternative to traditional health insurance. Through this ministry, members share each other’s medical expenses and offer mutual support through prayer during medical challenges. Medi-Share is not classified as insurance but as a not-for-profit ministry exempt from insurance regulation, providing a community-driven healthcare solution. It operates nationwide and promotes a Biblical approach to healthcare cost-sharing.

Christian Care Ministry (CCM) is a non-profit that administers Medi-Share, a healthcare sharing program where Christians come together to share each other’s medical bills. CCM employs more than 700 individuals in Melbourne, FL, Colorado Springs, CO and remotely throughout the United States.

Christian Care Ministry

• Works with leadership, clinical staff, key internal departments, and external customers to ensure optimum clinical outcomes for members
• Organizes, reviews, and interprets members’ medical records and compares them against proprietary program guidelines, CMS and FDA approved policies, and evidenced-based clinical criteria as appropriate to determine eligibility for bill sharing and advocacy for additional programs and interventions; determines if the medical record documentation supports the eligibility of requested and/or billed services
• Completes medical review casework as assigned and meets SLAs
• Abstracts review-related data/information accurately and timely in appropriate IT systems.
• Provides accurate and timely submission of all administrative and review-related documents to appropriate parties
• Provides appropriate consultation and referral to intra- and interdepartmental resources to ensure members receive optimum services offered by organization
• Makes case presentations to medical leadership for assistance in making sharing determinations
• Manages assigned clinical caseload meeting SLAs
• Delivers accurate and clear verbal and written communication to internal and external customers while complying with organizational HIPAA requirements
• Maintains accurate and timely records of all communications and interventions
• Performs ongoing process improvement for efficiencies and effectiveness
• Performs administrative and clinical processes to ensure team and departmental goals are met
• Contributes to the exercise and expression of Christian Care Ministry’s Christian beliefs
• All other duties as assigned

Clinical Reviewer II – LPN

Clinical Reviewer II at Christian Care Ministry assessing medical records for healthcare sharing eligibility. Collaborating with clinical staff to ensure optimal outcomes in a faith-based organization.

Hybrid Medical Reviewers Jobs

Browse 7 hybrid medical reviewers roles plus related opportunities such as medical writer, clinical research and medical director.

7 jobs found

Medical Reviewer II – Prior-Auth A/B MAC

BlueCross BlueShield of South Carolina

RN Medical Reviewer II

BlueCross BlueShield of South Carolina

RN Clinical Reviewer – IDR

Greenlife Healthcare Staffing

LPN Medical Reviewer I-2

BlueCross BlueShield of South Carolina

Surgical Clinical Reviewer

Connecticut Children's

Interner Kliniker, Clinical Reviewer

DQS

Clinical Reviewer II – LPN

Christian Care Ministry