Medical Review Manager (On-site or Fully Remote)

CGS Administrators LLC
life insurance, paid holidays, tuition assistance, 401(k)
United States, Tennessee, Nashville
2 Vantage Way (Show on map)
Feb 13, 2025
Summary We are currently hiring for a Medical Review Manager to join BlueCross BlueShield of South Carolina. In this role as a Medical Review Manager, you will oversee 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. 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. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Description Logistics This position is full time (40 hours/week) Monday-Friday from 8:00am-4:00pm and can be on-site or remote depending on the applicant's location. 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.as assigned by management. To Qualify for This Position, You Will Need: Graduate of Accredited School of Nursing OR Associate's in a job-related field. (Bachelor's degree required for the Celerian Group or Palmetto GBA). 5 years clinical and utilization review to include 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above. 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 Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC). Microsoft Office. What We Prefer: Previous Medicare/DME Experience Previous experience leading a team to meet specific KPI's and production points. Previous experience with data analysis Must have keen attention to detail. 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. 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 mycareer.help@bcbssc.com 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.