Certified Prosthetist Orthotist -Sr. Medical Reviewer-R1002160

Summary

Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided.

Description

•40% Functions as team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and work flow. Acts as resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.

•20% Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance work loads), reporting, and addressing aging issues.

•20% Participates in departmental quality reviews. Follows process to ensure quality plan is adhered to and communicated to all parties. Gives/receives feedback regarding medical review decision making and technical claims processing issues. Ensures that quality work instructions/forms/documents are developed/revised as needed.

•10% Provides quality service and communicates effectively with external/internal customers in response to inquiries. Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.

•10% Participates in compliance initiatives and other directed activities. Participates/oversees special projects as requested by management.

Required Education:

• Associate Degree in health-related field, OR
• Bachelor degree in health-related field, OR
• Master’s Degree in Occupational Therapy or Physical Therapy
• Certified prosthetist/orthotist (CPO) with current certification by either the American Board for Certification, (ABC) in prosthetics, orthotics and pedorthics, OR
• Board of Certification/Accreditation (BOC) in orthotics and prosthetics.

Required Work Experience:

• Four years of clinical experience, OR
• Two years of clinical experience and two years of medical review/utilization review, OR
• Combination of health plan, clinical, and business experience totaling four years.

Required Skills and Abilities:

• Working knowledge of managed care and various forms of health are delivery systems.
• Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
• Knowledge of specific criteria/protocol sets and the use of the same.
• Working knowledge of word processing and spreadsheet software. 
• Ability to work independently, prioritize effectively, and make sound decisions.
• Good judgment skills. 
• Demonstrated customer service, organizational, and presentation skills. 
• Demonstrated proficiency in spelling, punctuation, and grammar skills. 
• Demonstrated oral and written communication skills. 
• Ability to persuade, negotiate, or influence others. 
• Analytical or critical thinking skills. 
• Ability to handle confidential or sensitive information with discretion. 
• Ability to lead/direct/motivate others.

Required Software and Tools:

• Microsoft Office.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail abilities@bcbssc.com or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.