Utilization Review Nurse
The Utilization Review Nurse at BlueCross BlueShield of South Carolina plays a critical role in ensuring quality care and cost-effective services for our members. We are looking for an experienced, highly organized, and compassionate professional to join our team. Our ideal candidate should have an understanding of the South Carolina healthcare system, be able to work independently, and have strong problem-solving skills. The successful candidate will also be dedicated to providing exceptional customer service and creating positive outcomes for our members. Required Qualifications: Bachelors Degree in Nursing Registered Nurse with current license in South Carolina Minimum of two years of experience in utilization review and/or managed care Ability to interpret and apply health care policy and regulations Excellent written and verbal communication skills Ability to work independently and as part of a team Working knowledge of clinical practice guidelines, CMS regulations, and other regulatory agencies Proficient with Microsoft Office Suite and electronic medical record software Responsibilities: Evaluate healthcare services and providers to ensure quality care and cost-effectiveness Monitor utilization of services to ensure compliance with South Carolina healthcare regulatory requirements Develop clinical practice guidelines and protocols to ensure care is provided in line with current standards of practice Review and interpret policies, procedures, and regulations to ensure compliance Identify potential issues that could lead to overutilization of services Collaborate with providers to ensure efficient and effective utilization of services Provide education and support to members to encourage appropriate care utilization Utilize electronic medical record software and Microsoft Office Suite to enter and track health care services Develop reports to track utilization of services and identify trends Participate in meetings to discuss utilization trends, cost savings initiatives, and other related topics Respond to inquiries from members and providers regarding health care services 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. Apply Job!