Position Purpose: This role serves as the primary point of contact for all activities related to the Administrative Law Judge (ALJ) program. This includes medical record review, policy analysis and interpretation, preparing other ALJ team members for hearings, writing position papers for submission to the court, and testifying on behalf of CGS and the Medicare Program.

Logistics:  –one of BlueCross BlueShield's South Carolina subsidiary companies.

Location: This position is full-time (40 hours/week) Monday-Friday 8:00 AM-5:00 PM CST and will be hybrid or remote. The office is located at One Century Plaza, Nashville, TN.

• Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

• SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). As a Service Contract Act (SCA)employee, you are required to enroll in our health insurance, even if you already have other health insurance. Until your enrollment is complete, you will receive supplemental pay for health coverage. Your coverage begins on the first day of the month following 28 days of full-time employment.

• Sponsorship: This position is not eligible for sponsorship now or in the future.

What You Will Do:

• Provides clinical expertise, research, and judgment to develop Local Coverage Determinations (LCDS) under the direction of medical director. Maintains LCDS once developed.

• Educates providers and internal customers on LCDS. Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance.

• Provides clinical input for internal requests. Serves as reviewer to determine inter-rater reliability

To Qualify for This Position, You Will Need The Following:

• Required Education: Bachelor's in a job related field

• Degree Equivalency: Associate's degree in Nursing with an active RN license.

• Required Work Experience: 5 years clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.

• Required Skills and Abilities: Knowledge of managed care or medical claims payment policy issues. Working knowledge of word processing, spreadsheet software. Excellent verbal and written communication skills. Excellent customer service, organizational, presentation, analytical or critical thinking skills. Ability to persuade, negotiate, or influence others. Ability to handle confidential or sensitive information with discretion. Sound clinical review judgement. Independent thinking and strong organizational skills.

• Required Software and Tools: Microsoft Office.

• Required License and Certificate: An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC). For Division 33, Certified Genetic Counselor will be considered in lieu of RN License.

What We Prefer You Have The Following:

• Preferred Education: Bachelor's degree- Nursing.

• Preferred Work Experience: 7 years-clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.

• Preferred Skills and Abilities: Working knowledge of database software. Knowledge of government/healthcare programs and contracts laws, regulations. Knowledge of government/healthcare programs and regulations, coding, and approval practices. Knowledge of corporate administrative/medical policy for all lines of business. Knowledge of guidelines, benefits, and coverage for all lines of business.

• Preferred Software and Tools: Working knowledge of Microsoft Access or other database software, DB2 and Easytrieve.

• Preferred Licenses and Certificates: HIAA, CCM, MPH, MHA certifications.

• Work Environment: Typical office environment. Some travel required.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the first of the month following 28 days of employment.  

• 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

• Continuing education funds for additional certifications and certification renewal.

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 a recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

Salary Range:
Range Minimum

$55,251.00

Range Midpoint

$80,371.50

Range Maximum

$105,492.00

Pay Transparency Statement:

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.