Physician Advisor at BlueCross BlueShield of South Carolina

Columbia, South Carolina, United States -

Full Time

Start Date

Immediate

Expiry Date

07 Mar, 26

Salary

0.0

Posted On

07 Dec, 25

Experience

10 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medical Necessity, Utilization Management, Documentation Best Practices, Compliance, Clinical Reviews, Quality Improvement, Analytical Skills, Communication Skills, Organizational Skills, Customer Service, Negotiation Skills, Research Skills, Medical Policies, Coding, Healthcare Regulations, Team Collaboration

Industry

Insurance

Description

Summary The Physician Advisor optimizes efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. Provides assessment and determination of medical necessity in case evaluation and utilization management. Collaborates with a multidisciplinary team to implement methods and develop care management protocols that optimize the use BCBSSC services for all patients while ensuring quality care is provided. Description Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: The Physician Advisor optimizes efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. Provides assessment and determination of medical necessity in case evaluation and utilization management. Collaborates with a multidisciplinary team to implement methods and develop care management protocols that optimize the use BCBSSC services for all patients while ensuring quality care is provided. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment, with the opportunity to have a hybrid work schedule after training. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located at 4101 Percival Road, Columbia, SC 29229. What You’ll Do: Communicates with hospital physicians, care coordination and utilization management (UM) staff to champion best practices for evidence-based care and its documentation. Provides valuable guidance on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management, and compliance with governmental regulations. Performs UM review functions including pre-admission reviews, continues stay reviews, procedure precertification's, post-service reviews, emergency room visit reviews, and individual case management needs. Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion. Keeps abreast of current CMS and MCG evidence-based guidelines to enable UM decisions. Maintains compliance with legal, regulatory and accreditation requirements and payor partner policies. Uses, protects and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards. Serves as medical resource for quality improvement. Functions as liaison to medical community. Acts as resource for providers/internal staff on medical policies. Educates providers on issues concerning medical policies, utilization specifications, and coding/medical necessity issues. Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations. Participates in medical review policy/quality programs and inter-reviewer reliability studies To Qualify For This Position, You'll Need The Following: Required Education: Medical Doctor (MD) or Osteopathic Doctor (DO) with current license to practice. Required Work Experience: 8 years-broad clinical experience to include knowledge of utilization and medical review. Experience may include paid training. Required Skills and Abilities: Demonstrated ability to direct multiple strategic projects. Excellent verbal and written communication skills. Excellent judgment, organizational, customer service, presentation skills. Excellent analytical or critical thinking skills. Knowledge of strategic concepts. Ability to persuade, negotiate, or influence others. Required Software and Tools: Microsoft Office. Required Licenses and Certificates: Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty. We Prefer That You Have The Following: Preferred Experience: 2 years-medical data analysis/analytical capability to interpret statistical information. Preferred Skills and Abilities: Experience with medical oversight of quality improvement activities. Experience with quality committees or NCQA. Experience with population based disease management or public health initiatives. Experience in medical management or managed care. Demonstrated understanding of Medicare programs. Our Comprehensive Benefits Package Includes The Following: Subsidized health plans, dental and vision coverage 401k retirement savings plan with company match Life Insurance Paid Time Off (PTO) On-site cafeterias and fitness centers in major locations Education Assistance Service Recognition National discounts to movies, theaters, zoos, theme parks and more What We Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company. What To Expect Next: After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. 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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit. Welcome Here’s Your Smart Career Move Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. Join Us If you're ready to join in a diverse company with secure, community roots and an innovative future, apply for a position now!

Responsibilities

The Physician Advisor optimizes resource management and ensures patients receive appropriate care levels while supporting documentation and compliance. They collaborate with a multidisciplinary team to develop care management protocols and assess medical necessity.