Medical Review Supervisor (Medicare Part A - Prior Authorization) - CGS

Summary

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!

This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. While other companies are seeing a downturn, we are adding to our staff in strategic areas such as our Medicare Part A Medical Review team focusing on Prior Authorizations. We are adding five new staff to this team to provide better service to Medicare recipients.

This position will lead a team of four to ten Medical Reviewers. Responsible for the supervision and maintenance of the daily functions of Utilization Review, Case Management, and/or Medical Review staff and specialty programs. Ensures appropriate levels of healthcare services are provided. Will manage the team workload to ensure processing and quality metrics are met.

This administrative supervisory role will need strong attention to detail, clinical and computer skills. It will be best for someone who is a self-motivated leader that has excellent time management skills. No regular patient/provider contact. Excellent for those individuals looking to transition their career from the physical and time demands of direct patient care. The Monday through Friday daytime schedule with some flexibility, no regular weekends or holidays, provides the opportunity for a good home/work life balance.

Description

Logistics:

• Preferred candidate will live within 40 miles of Nashville, TN or Columbia, SC. If living in Nashville or Columbia, this will be an onsite position. Hybrid schedule may be considered.
• Superior candidates with preferred experience and skills will also be considered. These candidates will work from home, if selected. To work from home, you must have high-speed internet (non-satellite) and a private home office.
• Work hours are 8:00 am to 4:30 pm CT. Monday through Friday. Once you complete training and meet performance and quality standards, you may flex up to four hours per week with supervisor approval.
• Target hire date: 12/09/2024
  
  

What You Will Do

• Manages day-to-day activities for assigned staff. Identifies training needs and verifies accuracy and timeliness of workflow functions.
• Supervises staff to include approval of time, leave, performance reviews, etc. Selects/trains/motivates staff in providing excellent customer service with customers, marketing, management/others.
• Performs quality control functions for work performed. Develops work plans to improve quality performance. Prepares/reviews/maintains weekly/monthly reports.
• Develops/maintains/updates procedures/documentation for conducting audits. Develops/communicates department standards and expectations of staff. Coordinates special projects, system testing enhancements, etc.
  
  

What We Require You Have

• Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC),
• Required Education: Associates in a job-related field OR graduate of Accredited School of Nursing.
• Required Work Experience: Five years clinical OR five years utilization review/medical review experience (Three of the five must be clinical). One year team lead/leadership role or equivalent military experience in grade E4 or above (may be concurrent with the five years).
• Required Skills and Abilities: Working knowledge of word processing, spreadsheet, and database software. Ability to work independently, prioritize effectively, and make sound decisions. Working knowledge of managed care and/or various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to lead, motivate, and assess performance of others.
• Required Software and Tools: Microsoft Office.
  
  

What We Prefer You Have

• Five years clinical experience as a Registered Nurse in the following specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A or Utilization Management.
• Experience with HOPD (Hospital Outpatient Department) and Prior Authorization of RSNAT (Repetitive, Scheduled Non-Emergent Ambulance Transport).
• Ability to work with multiple windows-based programs simultaneously.
• Developing and using validation reports.
• Intermediate Word, Excel and Outlook skills.
  
  

What We Can Do For You

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.
  
  

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 a 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.

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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 [email protected] 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.