Summary
 

We are looking for a Registered Nurse with strong leadership and analytical skills to guide our Home Health & Hospice Medical Review Team. Oversee the performance, productivity, and quality of the medical claims review staff. Team includes clinical medical reviewers and claims processor. Evaluate medical claims review processes and implements process improvements. Serves as a resource for all medical review team members. Coach, mentor, and develop staff. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Responsible for the planning and development of the medical review strategy. Review claims data that includes activity reports and spreadsheets, to plan strategy, monitor and measure departmental productivity, goal achievement, and overall effectiveness.

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.

Description
 

Logistics:

• Preferred candidate will live in the Nashville, TN area. If living in Nashville, this will be an onsite position.

• Superior candidates living outside of the Nashville area will be considered. These candidates will be able to work from home. To work from home, you must have high-speed internet (non-satellite) and a private home office. You also must be able to attend meetings and trainings in the Nashville, TN office as needed.

What You Will Do

• Manages the medical review process. Maintains a well-trained staff. Develops/implements medical review strategy with the ultimate goal of reducing the error rate. Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations. Identifies missed standards and implements corrective actions.

• Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action. Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner.

• Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required to build and maintain positive customer relationships.

What You Need to Qualify

• Required Education: Bachelor's Degree - Nursing

• Required Work Experience: Five years clinical and utilization review to include two years supervisory or team lead experience or equivalent military experience in grade E4 or above.

• Required Skills and Abilities: Knowledge of Part A and Part B Medicare benefit/regulations/policies/instructions. Knowledge of systems (FISS and MCS)/processing procedures for Medical Review. 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 License and Certificate: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

• Required Software and Tools: Microsoft Office.

What We Prefer You Have

• Medicare Administrative Contractor (MAC) experience.

• 2 years Home Health & Hospice Utilization Review or Medical Review experience.

• Process improvement experience.

• Understanding of clinical/medical data.

• Strong writing and analytical skills.

• Basic ICD-10 coding knowledge.

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 access and opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Our comprehensive benefits package includes:

• 401(k) retirement savings plan with company match

• Fantastic 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 a healthy lifestyle premium discount

• Tuition assistance

• Service recognition

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 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.