Utilization Review Nurse
<p>We at BlueCross BlueShield of South Carolina are looking for a motivated and experienced Utilization Review Nurse to join our team. The successful candidate will be responsible for ensuring the quality and cost-effectiveness of medical services through analysis of utilization data. If you are passionate about delivering high quality healthcare and possess the necessary qualifications, this could be an excellent opportunity for you.To be considered for this role, you must have a valid Registered Nurse License and have a minimum of three years of experience in utilization review, case management, or clinical care. You must also possess a strong knowledge of private health insurance policies, medical coding, and standards of care. Previous experience in a managed care environment is also preferred.The successful candidate should possess excellent organizational, communication, and problem-solving skills. They must also be able to collaborate effectively with interdisciplinary teams and be comfortable working with limited direction. An ability to work independently and prioritize tasks is essential. Responsibilities: Analyze utilization data to ensure quality and cost-effectiveness of medical services Ensure compliance with private health insurance policies, medical coding, and standards of care Provide clinical guidance and expertise to interdisciplinary teams Review and adjust utilization reviews to ensure accuracy and compliance Monitor utilization trends and recommend changes to utilization review processes Assist in the development and implementation of utilization management plans Maintain organized records of utilization review activities Provide education and training to staff, providers, and other stakeholders Assist in the development and implementation of quality improvement initiatives Monitor the effectiveness of utilization review activities and take appropriate corrective action when necessary</p><p>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.</p>
