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. Selected candidates will be reviewing medical records to determine medical necessity, eligibility under Medicare guidelines and identify fraud and abuse of the Medicare system.

This administrative role will need strong clinical and computer skills. It will be best for someone who is self-motivated and 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:

• The preferred candidate will live within 40 miles of Nashville, TN, or Columbia, SC. If living in Nashville or Columbia, this will be an on-site position. A hybrid schedule may be considered.

• Superior candidates with preferred experience and skills will also be considered. If selected, these candidates will work from home. You must have high-speed internet (non-satellite) and a private home office to work from home.

• Work hours are 8:00 a.m. to 4:30 p.m. 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.

• Class start date: 12/09/2024

What You Will Do:

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity, appropriateness, and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.

• Educates internal and external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc., in accordance with contractor guidelines.

• Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned 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: Associate in a job-related field OR graduate of an Accredited School of Nursing.

• Required Work Experience: Two years of clinical nursing experience.

• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.

• Required Software and Tools: Microsoft Office.

What We Prefer You Have:

• Five years of clinical experience as a Registered Nurse, including two years in the following specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A, or Utilization Management.

• Ability to work with multiple Windows-based programs simultaneously.

• Intermediate Word, Excel, and Outlook skills.

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits on the first of the month following 28 days of employment.  

• 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

• Tuition Assistance

• Service Recognition

• Employee Assistance

• Discounts to movies, theaters, zoos, theme parks and more

What We 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.

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 our recruiter to verify resume specifics and salary requirements. Management will conduct interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the required 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 [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.