BlueCross BlueShield of South Carolina RN Senior Medical Reviewer in Birmingham, Alabama

RN Senior Medical Reviewer

Position Summary

  • Acts as team lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction, guidance and training to staff.

  • Ensures appropriate levels of health care services are provided.

Required Education

  • Associate degree in Nursing OR, a four-year degree in health-related field, OR

  • Graduate of accredited School of Nursing.

Required Work Experience

  • Four years of clinical experience OR , two years of clinical experience and two years of medical review/utilization review OR , combination of health plan, clinical and business experience totaling four years.

  • Medicare experience

Required Skills and Abilities

  • Working knowledge of managed care and various forms of health care delivery systems.

  • Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.

  • Knowledge of specific criteria/protocol sets and the use of the same.

  • Working knowledge of word processing and spreadsheet software.

  • Ability to work independently, prioritize effectively, and make sound decisions.

  • Good judgment skills.

  • Demonstrated customer service, organizational and presentation skills.

  • Demonstrated proficiency in spelling, punctuation and grammar.

  • Demonstrated oral and written communication skills.

  • Ability to persuade, negotiate with and influence others.

  • Analytical or critical-thinking skills.

  • Ability to handle confidential or sensitive information with discretion.

  • Ability to lead/direct/motivate others.

  • Microsoft Office.

  • If RN, active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC), OR active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.

Work City Birmingham

Work State AL

EEO Statement

We are an Equal Opportunity/Affirmative Action Employer. We will consider all qualified applicants for employment 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.