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Medical Reviewer II (Prior-Auth A/B MAC) – CGS ID-5495

About the position

Join the BlueCross BlueShield of South Carolina family of companies, a long-standing leader in the insurance industry with over seven decades of service. We are the largest insurance company in South Carolina and a prominent administrator of government contracts. Our subsidiary, CGS Administrators, has been providing administrative and business services for state Medicaid agencies, managed care organizations, and healthcare providers for over 50 years. This position involves reviewing medical records to assess medical necessity and eligibility under Medicare guidelines, while also identifying potential fraud and abuse. Ideal candidates will possess strong clinical and computer skills, be self-motivated, and have excellent time management abilities. This role offers a balanced work-life schedule with no regular weekends or holidays.

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Responsibilities
• Perform medical claim reviews for complex services, preauthorization requests, appeals, and potential fraud cases.
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• Make payment determinations based on clinical information and established criteria.
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• Determine medical necessity and appropriateness for coverage and reimbursement.
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• Monitor process timeliness according to contractor standards.
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• Document medical rationale for payment or denial of services.
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• Educate internal and external staff on medical reviews, terminology, and coding procedures.
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• Participate in quality control activities and provide guidance to LPN team members.
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• Assist with special projects and responsibilities as assigned by management.

Requirements
• Active, unrestricted RN licensure from the United States or a compact multistate unrestricted RN license.
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• Associate degree in a job-related field or graduate of an Accredited School of Nursing.
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• Two years of clinical nursing experience.
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• Working knowledge of word processing software.
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• Ability to work independently and prioritize effectively.
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• Good judgment and demonstrated customer service skills.
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• Strong oral and written communication skills.
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• Analytical or critical thinking skills.
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• Ability to handle confidential information with discretion.
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• Proficiency in Microsoft Office.

Nice-to-haves
• Five years of clinical experience as a Registered Nurse, including two years in Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.
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• Ability to work with multiple Windows-based programs simultaneously.
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• Intermediate skills in Word, Excel, and Outlook.

Benefits
• Subsidized health plans, dental, and vision coverage
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• 401K retirement savings plan with company match
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• Life Insurance
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• Paid Time Off (PTO)
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• On-site cafeterias and fitness centers in major locations
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• Tuition Assistance
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• Service Recognition
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• Employee Assistance
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