Utilization Review Nurse

The Utilization Review Nurse role at BlueCross BlueShield of South Carolina is an exciting opportunity for a talented and experienced nurse to make a substantial contribution to our medical services team. We are looking for a nurse who is passionate about providing quality healthcare services to the members in our community. The ideal candidate for this position will be a motivated self-starter with a desire to work in a fast-paced environment. The successful candidate will have a strong background in nursing, with a minimum of 3 years of experience in a medical services role. In addition, the successful candidate must have a valid RN license in South Carolina, be well-versed in medical terminology, possess strong interpersonal skills, and be highly organized and detail-oriented. Excellent computer skills are also a must. We are looking for a professional who is motivated, driven, and passionate about providing our members with the best quality care. If you are looking for an opportunity to make a positive impact in the lives of our members, we want to hear from you.

Responsibilities: Coordinate with providers and review medical records to ensure compliance with quality and cost standards Identify opportunities for improvement in care services Establish performance standards and evaluate the effectiveness of quality assurance activities Monitor utilization and activity data to anticipate and reduce costs Evaluate requests for services based on clinical criteria and make decisions as to the appropriateness of care and services Make referrals to appropriate services and resources Consult with providers and other healthcare professionals to ensure quality of care Provide education and training to physicians, other healthcare providers, and members on utilization management and quality assurance processes Document utilization activities in accordance with state and federal regulations Maintain confidentiality of patient information Perform other related duties as required.

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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