APPLY DIRECTLY AT: https://ourhrconnect.wd5.myworkdayjobs.com/en-US/SCBlues/details/Medical-Review-Director_R1040346
CGS Administrators is seeking a Medical Review Director. This role directs and oversees operations in the medical review, clinical pricing, and re-determination areas ensuring performance expectations, compliance standards, and budgetary limits are maintained. Supervises and motivates area employees.
Logistics:
This position is full-time (40 hours/week, 8 hours/day) Monday – Friday onsite in Nashville, TN
What You'll Do:
- 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..
To Qualify for This Position, You'll Need:
- Required Education: Bachelor's degree - Business Administration, Healthcare Administration, Nursing, or other related field.
- Required Work Experience: Five years healthcare program management, utilization/case management, or medical review management or equivalent military experience in grade E4 or above.
- Required Software and Tools:
- Ability to use standard office equipment.
- Knowledge of word processing, spreadsheet, and database software.
- Knowledge of medical management systems.
- Required Skills and Abilities:
- 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.
We Prefer You to Have:
- Strong Microsoft Office Skills
- Proficiency in Excel
- Medicare experience with claims and medical review
- Experience leading leaders
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!
What Blue 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.
Our comprehensive benefits package includes:
- 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
- Wellness program and healthy lifestyle premium discount
- Tuition assistance
- Service recognition
- Employee Assistance
- Discounts to movies, theaters, zoos, theme parks and more
What to Expect Next:
APPLY DIRECTLY AT: https://ourhrconnect.wd5.myworkdayjobs.com/en-US/SCBlues/details/Medical-Review-Director_R1040346
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.
Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Here's more information.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Here's more information.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
Job Type: Full-time
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Experience:
- Utilization review: 3 years (Required)
License/Certification:
Ability to Commute:
- Nashville, TN 37214 (Required)
Ability to Relocate:
- Nashville, TN 37214: Relocate before starting work (Required)
Work Location: In person
