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 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 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.

Join a great team dedicated to reviewing dental and oral maxillofacial claims. Act as Team Lead for dental review, specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensure appropriate levels of healthcare services are provided. Conduct quality reviews, develop work instructions, communicate work status and metric compliance. Develop process improvement initiatives.

Description
 

Logistics:

• This is a work from home opportunity. To work from home, you must have high-speed internet (non-satellite) and a private home office.

• Those living within driving distance of the Nashville, TN office will work onsite.

• Work hours are 8:00 am to 5:00 pm CT. Monday through Friday.

What You Will Do:

• Functions as team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains working knowledge of unit functions and ability to interpret to new hires, department interworkings and workflow. Acts as resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews. Follows process to ensure quality plan is adhered to and communicated to all parties. Gives/receives feedback regarding medical review decision making and technical claims processing issues. Ensures that quality work instructions/forms/documents are developed/revised as needed.
• Provides quality service and communicates effectively with external/internal customers in response to inquiries. Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participates in compliance initiatives and other directed activities. Participates/oversees special projects as requested by management.

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: Four years clinical, OR, Two years clinical and two years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling four years.

• Required Skills and Abilities: Working knowledge of managed care and various forms of health are 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. Working knowledge of word processing and spreadsheet software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication 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/direct/motivate others.

• Required Software and Tools: Microsoft Office.
   

What We Prefer You Have:

• Dental claims review OR oral maxillofacial surgery experience, strongly preferred.

• Intermediate computer experience with the ability to work with multiple Windows programs simultaneously.

• Ability to adapt to change.

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 the most qualifies candidates.

 

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.