Utilization Review Nurse

We are seeking an experienced, compassionate Utilization Review Nurse to join our team at BlueCross BlueShield of South Carolina. In this important role, you will evaluate and assess the medical necessity, appropriateness, and efficiency of medical services provided to members. You will be responsible for ensuring our members receive the care they need to live healthier lives. The ideal candidate will have a strong clinical background, excellent interpersonal skills, and a passion for providing excellent customer service. The successful candidate will possess the following qualifications: Current RN licensure in South Carolina, 5+ years of clinical nursing experience in an acute care setting, working knowledge of medical coding and managed care principles, and experience with utilization review and quality assurance activities. Knowledge of Medicare, Medicaid, and other health plan regulations is preferred. The successful candidate must also have strong critical thinking and problem-solving skills, excellent communication and organizational skills, and an understanding of customer service principles.

Responsibilities: Analyze and assess the medical necessity, appropriateness, and efficiency of medical services provided to members. Ensure members receive the care they need to live healthier lives. Utilize medical coding and managed care principles in day-to-day operations. Participate in utilization review and quality assurance activities. Monitor and maintain compliance with Medicare, Medicaid, and other health plan regulations. Develop and implement programs and procedures to maximize members' satisfaction. Provide guidance and support to staff regarding utilization review and medical necessity criteria. Monitor and review utilization data and provide feedback to providers. Maintain up-to-date knowledge of healthcare industry regulations and standards. Provide excellent customer service to members, providers, and other stakeholders.

BlueCross BlueShield of South Carolina is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate based upon race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.

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