Medical Review Director - CGS Administrators, LLC

BlueCross BlueShield of South Carolina•Nashville, TN

2d•Onsite

About The Position

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. 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 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! Position Purpose: The Medical Review Director directs and oversees operations in the medical review, clinical pricing, and re-determination areas ensuring performance expectations, compliance standards, and budgetary limits are maintained. In this role, you will supervise and motivate area employees. Description Logistics: CGS Administrators, LLC - one of BlueCross BlueShield of South Carolina’s subsidiary companies. Location: This position is full-time (40-hours/week) Monday-Friday ONSITE in a typical office environment. 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 can be physically located in Nashville, TN, Columbia, SC, or Springfield, IL. There are no options for remote or hybrid work schedules. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Requirements

Bachelor's in a job related field.
5 years healthcare program management, utilization/case management, or medical review management.
3 years of supervisory/management experience or equivalent military experience in grade E4 or above.
Microsoft Office.
Knowledge of medical systems software.
Excellent verbal and written communication skills.
Excellent organizational, customer service, analytical or critical thinking skills.
Excellent presentation skills.
Good judgment skills.
Ability to persuade, negotiate, or influence others.

Nice To Haves

Bachelor's degree - Nursing
Graduate of Accredited School of Nursing
Experience working with CMS and/or Medicare.
Working knowledge of Medicare claims processes and the Medicare program.
Strong understanding of using data to make business decision.
Knowledge/understanding of utilization review guidelines, managed care delivery systems.
Ability to work independently, prioritize effectively, make sound decisions.
Demonstrated presentation skills in order to work effectively with both internal and external customers.
Ability to handle confidential or sensitive information with discretion.
Ability to direct, motivate, and assess performance of others.
Active RN licensure in state hired.

Responsibilities

Oversees operations of assigned areas.
Coordinates tactical team activities.
Ensures area review decisions are accurate and all associates are well informed and trained on contract process work instructions.
Reviews and analyzes data and creates departmental strategy and error rate reduction plans based on the findings.
Provides guidance on the analysis, identification, and corrective actions of services and/or providers with suspected abuse of the program.
Works closely with the Provider Service Center and other internal departments, providing necessary assistance and resources, to ensure consistency and achieve the integrated goals of reducing the claims payment error rate and procurement of additional contracts.
Develops and monitors budget for all assigned areas.