SummaryAnalyzes medical review utilization data, researches new medical procedures or technology, and acts as a lead resource to providers and internal staff on issues concerning medical policies. Heavily involved in policy generation to include the development of new policy and the revision of old policy. This role is centered on policy expertise rather than organizational clinical leadership. While highly impactful, the scope is focused on Medicare policy development, interpretation, and guidance. It does not include enterprise clinical leadership, direct reports, or executive-level strategic ownership.
DescriptionLogistics- CGS (cgsadmin.com) - one of BlueCross BlueShield's South Carolina subsidiary companies.
Location:- This position is full time (40 hours/week) Monday through FridayThis is a W[redacted] opportunity and can be located anywhere within the U.S.
- To work from home, you must have high-speed, non-satellite internet and a private home office space.
Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You Will Do:- Supports operations in the form of case review on both medical and regulatory matters. Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.
- Educates staff and medical community on various aspects of medical policy and program administration.
- May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies. Develops external relationships with the medical community and serves as liaison between these entities and the contractors.
- Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
- Conducts research into new or controversial medical procedures and technology.
To Qualify for This Position, You Will Need:- Required Education: Doctorate in a job-related field
- Required Licenses and Certificates: Active state medical license and current board certification in a recognized specialty.
- Required Work Experience: 5 years post graduate experience in direct patient care.
- Required Skills: Excellent verbal and written communication skills. Excellent customer service, organizational, and presentation skills. Good judgment skills. Proficiency in spelling, punctuation, and grammar. Ability to persuade, negotiate, or influence others. Ability to work as a team member as well as a leader. Knowledge of medical and utilization review techniques.
- Required Software: Microsoft Office.
What We Prefer:- Highly inquisitive, Self-Starter
- Advanced problem solving skills
- Medicare Part A experience
- Strong client facing, relationship building skills
- Ability to follow the Scientific Method
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
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.
