Utilization Review Nurse

Are you a compassionate, detail-oriented Utilization Review Nurse looking for an opportunity to make an impact on the healthcare industry? BlueCross BlueShield of South Carolina (BCBSSC) is currently seeking experienced Utilization Review Nurses to join our team. In this role, you will be responsible for reviewing patient care plans and making sure they meet quality standards. The ideal candidate should have a thorough understanding of medical and coding terminology, as well as excellent communication and organizational skills. If you have a passion for improving the quality of healthcare for our members, we would love to hear from you!Required Qualifications:* A current, active RN license in the state of South Carolina* A minimum of 3 years of experience in the utilization review field, preferably in a managed care setting* Knowledge of payer and provider policies and procedures related to utilization management* Experience with utilization management software and electronic medical records* Ability to work in a fast-paced environment and manage multiple tasks* Excellent written and verbal communication skills

Responsibilities:

Review patient care plans to ensure they meet quality standards and comply with BCBSSC regulations.
Utilize utilization management software and electronic medical records to assess patient care plans.
Communicate with payers and providers to ensure the accuracy of patient care plans.
Monitor patient care plans to ensure they are up-to-date and in compliance with BCBSSC regulations.
Vet and approve changes to patient care plans based on changes in medical codes, payer policies, or provider procedures.
Track patient outcomes and make recommendations for improvement.
Provide education and guidance to providers and staff on utilization management policies and procedures.
Evaluate and review patient medical records to ensure accuracy and compliance.
Collaborate with other healthcare professionals to ensure the best quality of care for patients.
Stay up-to-date on changes in healthcare regulations and payer policies.

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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