Utilization Review Nurse

We are seeking an experienced and knowledgeable Utilization Review Nurse to join the BlueCross BlueShield of South Carolina team. The ideal candidate will be highly organized, with excellent communication and interpersonal skills. In this role, you will use your expertise to provide efficient and effective utilization review services for members and providers.To be successful in this role, you will need a current Registered Nurse (RN) license and a minimum of 3 years of experience in utilization review in a managed care setting. A Bachelor of Science in Nursing (BSN) or certification in utilization review is preferred. A comprehensive knowledge of medical coding and a strong understanding of medical terminology, diagnosis and procedures is also essential.You must be a team player with the ability to work independently and with minimal supervision. In addition, you must have excellent problem-solving skills and the ability to work in a fast-paced environment. Finally, you should be able to interact professionally with members, providers, and other team members, and have a strong commitment to quality service.

Responsibilities:

1. Conduct utilization review processes for members and providers in accordance with BlueCross BlueShield policies and procedures.
2. Ensure compliance with applicable state and federal regulations.
3. Evaluate patient records to ensure medical necessity and appropriateness of services.
4. Monitor utilization statistics and trends and provide recommendations for improvement.
5. Collaborate with other departments to resolve member and provider inquiries.
6. Provide education to members and providers regarding utilization review processes.
7. Maintain a high level of confidentiality and privacy in regards to patient information.
8. Develop and implement utilization management plans.
9. Participate in review and development of utilization review policies and procedures.
10. Monitor utilization and cost containment initiatives.

According to JobzMall, the average salary range for a Utilization Review Nurse in Greer, SC, USA is $58,937 to $88,577 per year. The salary range may vary depending on the experience of the nurse, the employer, and any applicable bonuses or incentives.

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. BlueCross serves 21.5 million people through private business and government contracts.