Summary
Oversees the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities.
Description

Position Purpose:

Oversees the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities, while helping to manage and hold the team accountable for quality standards within their work. Manages and oversees the accurate processing of claims deferred for medical necessity review, ensuring adherence to nationally recognized standards as well as local, state, and federal regulations. Drives continuous improvement by identifying and implementing process enhancements, while supporting team accountability and maintaining high-quality performance standards.

Logistics: CGS (cgsadmin.com) - one of BlueCross BlueShield of South Carolina's subsidiary companies.

Location: This is a full-time position (40 hours per week), Monday through Friday, based in a collaborative office environment during standard business hours of 8:00 AM to 5:00 PM. The primary work location is 26 Century Blvd., Suite ST610, Nashville, TN 37214. Depending on business needs and individual circumstances, remote or hybrid work arrangements may be available for qualified and interested candidates.

What You'll Do:

• Manages the medical review process.
• Maintains a well-trained staff.
• Develops/implements medical review strategy with the ultimate goal of reducing the error rate.
• Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations.
• Identifies missed standards and implements corrective actions.
• Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action.
• Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner.
• Interfaces with internal and external customers such as appellants/attorneys, congressional offices , and other regulatory bodies as required to build and maintain positive customer relationships.

To Qualify For This Position, You'll Need:

• Required Education: Bachelor's degree in a job-related field.
• Required Work Experience: 5 years clinical and utilization review to include 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above.
• Required Skills and Abilities: Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills. Good judgment skills. Proficient spelling, grammar, punctuation, and basic business math. Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion. Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

We Prefer That You Have:

• Demonstrated expertise in Medicare claim reviews (Appeals, Utilization Review, Part A, HHH), and a thorough understanding of Medicare policies/coverages/regulations.
• Demonstrated experience leading teams of 15-20 professionals across clinical and non-clinical functions, with a consistent focus on maintaining high-quality standards.
• Strong commitment to continuous process improvement and operational efficiency.
• Proven experience managing.

Our Comprehensive Benefits Package Includes:

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

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.