Senior Medical Review Director

BlueCross BlueShield of South Carolina

2d•Remote

About The Position

Summary Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for government programs. This role Directs and oversees the Medical Review and Prior Authorization programs ensuring performance expectations, compliance standards, workload issues, quality control, training and maintaining effective staffing levels and budgetary limits are maintained per the Center for Medicare and Medicaid Service (CMS) guidelines. Guides the Medical Review Team in the development and implementation of an efficient and effective Medical Review Strategy, including the integration of policy and education, that optimizes critical Medical Review cycle times. Serves as the Medical Review and Prior Authorization liaison between internal and external stakeholders. 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: Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for government programs. This role Directs and oversees the Medical Review and Prior Authorization programs ensuring performance expectations, compliance standards, workload issues, quality control, training and maintaining effective staffing levels and budgetary limits are maintained per the Center for Medicare and Medicaid Service (CMS) guidelines. Guides the Medical Review Team in the development and implementation of an efficient and effective Medical Review Strategy, including the integration of policy and education, that optimizes critical Medical Review cycle times. Serves as the Medical Review and Prior Authorization liaison between internal and external stakeholders.

Requirements

Bachelor's in a job related field
10 years healthcare program management, utilization/case management, or medical review management or equivalent military experience in grade E4 or above.
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.
Ability to evaluate existing processes and develop ways to streamline procedures.
Strong organizational, analytical, communication, and decision-making skills.
Knowledge of budget preparation and management.
Ability to handle difficult situations.
Ability to easily adapt to change.
Microsoft Office.
Knowledge of medical systems software.
If RN, active RN licensure in state hired.

Nice To Haves

8 years of Medicare program management, utilization/case management, or medical review management or equivalent military experience grade E4 or above. May be concurrent.
In-depth knowledge of the Medicare Medical Review and Prior Authorization program.
Knowledge of CMS change process.
Knowledge of Medicare laws, regulations, and guidelines.
Excellent decision making and problem solving.
Demonstrated knowledge of developing, monitoring, and overseeing budgets.
American Society for Quality Certification.

Responsibilities

Ensure system/operational compliance with CMS directives.
Establish, guide and analyze the effectiveness of Medical Review and Prior Authorization operations against benchmarks that are developed as measures of success.
Analyze performance trends and develop new/modified work processes to improve overall operations quality/timeliness/customer satisfaction/financial outcomes.
Direct/develop/evaluate/motivate subordinates to achieve and maintain production and quality standards ensuring area review decisions are accurate and all associates are well informed and trained on contract process work instructions.
Directs and oversees the development of the Medical Review and Prior Authorization Program strategy and error rate reduction plans based on the findings.
Develop and implement the Medical Review Programs strategic plan with goals supportive of the corporate strategic plan.
Manage budget to ensure cost effectives and performance quality.
Serve as the liaison and maintain proactive working relationship with CMS and other Medicare program leadership as needed by contract.
Investigate and resolve action items assigned by executive management.
Resolve priority level problems from providers, beneficiaries, and CMS.