Utilization Review Nurse

BlueCross BlueShield of South Carolina is seeking an experienced Utilization Review Nurse to join our team. The ideal candidate will have a passion for providing excellent patient care and a commitment to upholding the highest standards of medical quality assurance.The Utilization Review Nurse will be responsible for ensuring that our members receive the most cost-effective, medically necessary care. This position requires a strong understanding of healthcare policy, reimbursement processes, and healthcare delivery systems, as well as excellent communication and problem-solving skills.The successful candidate will have an active Registered Nurse license in South Carolina and a minimum of three years of experience in a hospital, ambulatory care, or managed care setting. Previous experience in utilization management is preferred. This position also requires thorough knowledge of applicable laws, regulations, and payer policies. The ideal candidate will also have excellent interpersonal skills and the ability to interact with members, providers, and other health system personnel effectively. Experience with a computerized utilization management system is a plus.If you are an experienced Utilization Review Nurse who is passionate about providing excellent care and wants to join a dedicated team of healthcare professionals, we want to hear from you!

Responsibilities of the Utilization Review Nurse:

• Monitor and evaluate utilization of healthcare services to ensure that members receive the most cost-effective, medically necessary care

• Ensure compliance with applicable laws, regulations, and payer policies

• Review medical records and other documentation to assess the medical necessity and appropriateness of services

• Collaborate with members, providers, and other health system personnel to ensure appropriate and timely delivery of services

• Analyze utilization data to identify trends and opportunities for improvement

• Develop and implement strategies to improve utilization and cost containment

• Monitor and report utilization to ensure that services are appropriately used

• Utilize a computerized utilization management system to facilitate timely and accurate processing

• Provide education and training on utilization review, reimbursement, and medical quality assurance

• Maintain current knowledge of healthcare policy, reimbursement processes, and healthcare delivery systems

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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