Summary
 

Oversees the accurate processing of claims that have been deferred for medical necessity review.

Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations.

Identifies and implements process improvement opportunities.
CGS Administrators provides a variety of services, under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, health care providers, and medical equipment suppliers in 33 states, supporting the needs of more than 20 million Medicare beneficiaries nationwide.



CGS Administrators, LLC is part of the Celerian Group, a consortium of companies which act as subsidiaries to BlueCross BlueShield of South Carolina, that helps government and private health care plans navigate the complexities of benefits administration.



We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Description
 

Position Purpose:

This role manages the medical review process and maintains a well-trained staff by developing and implementing medical review strategy with the ultimate goal of reducing the error rate. This job can be complex and requires metric monitoring for timeliness of review, quality of decisions, productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations.  You also will need to have extensive knowledge of Medicare policy and coding guidelines specific to Home Health and Hospice Services and the ability to interpret, adapt and apply CMS guidelines.

We look to data to drive our direction and conclusions, so we will look to you to bring your experience and skills for analyzing medical records and billing data to generate reports and draw meaningful conclusions.  As a subject matter expert, our ideal candidate will have experience in developing policies and procedures, someone who is comfortable dealing with ambiguity, and has a bias for turning plans into action. 

Logistics:

• This position is full-time (40 hours/week) Monday-Friday in a typical office environment.  Employees are required to have flexibility to work any of our 8-hour shift scheduled during our normal business hours of 8:00 AM – 6:00 PM. It may be necessary, given the business need to work occasional overtime and weekends.
• Preferred candidate will live in Nashville, TN area. For those living in Nashville, the position would be hybrid (in-office and work from home).
• Highly qualified candidates outside the Nashville area will also be considered. For those living outside Nashville area, the position will be fully remote.
• To work from home, you must have high-speed (non-satellite) internet and a private home office.

What You’ll Do:

• You’ll be focused on proactively overseeing the accurate processing of claims that have been deferred for medical review.
• You will guide your team to review medical records and to ensure compliance with nationally recognized standards, and local, state, and federal laws and regulations.
• Accurately identifying and implementing process improvements and opportunities is vital for the success of this role. You are the subject matter expert for this role.
• Through the leadership of your team and recommendations to executive management, you will bring forward recommendations, feedback, process improvements, and assistance with special projects to make positive changes for the department/company.

To Qualify for This Position, You’ll Need:

• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
• Education: A Bachelor’s Degree - Nursing or related field.
• Experience: Five (5) years clinical and utilization review to include two or more years supervisory or team lead experience or equivalent military experience in grade E4 or above.
• Skills/Abilities: Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills. Good judgment skills. Proficient spelling, grammar, punctuation, and basic business math. Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion. Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes.
• Required Software and Tools: Microsoft Office.

 

We Prefer That You Have:

• Experience: MAC (Medicare Administrative Contractor) experience strongly preferred. Process improvement experience. Case management or utilization review experience.
• Skills/Abilities: Knowledge of Part A Home Health and Hospice Medicare benefits, regulations, policies, and/or instructions. Knowledge of Medicare payment systems (FISS )/processing procedures for Medical Review Understanding of clinical/medical data. Analytical skills. Strong organizational skills. Demonstrates ability to deal with ambiguity and turn plans into action. Ability to present/ train on complex information groups.
• Software and Tools: Strong proficiency in Microsoft Office skills such as Excel, PowerPoint, Word.

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 be conducting interviews with those candidates who qualify and satisfy assessment requirements, with the most qualified candidates.

 

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.