Utilization Review Nurse

We at BlueCross BlueShield of South Carolina are searching for a highly motivated and qualified Utilization Review Nurse to join our team. This position requires an experienced and passionate individual who is committed to helping our members receive the best possible care. The successful candidate must have a current South Carolina nursing license and a valid RN license. They must also have a minimum of two years of experience in utilization review, care management, or case management. Expertise in medical terminology, CPT and ICD-10 coding, clinical documentation, and health insurance policies and regulations is a must. The Utilization Review Nurse must also possess excellent communication and interpersonal skills and be able to work both independently and collaboratively. We are looking for an individual who is committed to helping our members make informed decisions about their healthcare. If you have the qualifications and enthusiasm to join our team, we look forward to hearing from you.

Responsibilities:

Adhere to all South Carolina nursing laws and regulations and maintain a current RN license.
Utilize expertise in medical terminology, CPT and ICD-10 coding, clinical documentation, and health insurance policies and regulations.
Evaluate patient medical records and determine the appropriateness of services provided according to established standards.
Review medical claims to ensure that appropriate charges are billed to the insurance company.
Collaborate with physicians and other healthcare professionals to ensure that patients receive the most effective and efficient care possible.
Maintain detailed records and documentation of all interactions with patients, physicians, and other healthcare providers.
Communicate effectively and professionally with members, healthcare providers, and other stakeholders.
Keep up-to-date with industry and regulatory changes and ensure compliance with all applicable laws and regulations.
Monitor utilization trends and collaborate with healthcare providers to identify opportunities for improvement.
Assist members in making informed decisions about their healthcare.

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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