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SummaryOversees 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.Description
*70% 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.
*20% 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.
*10% 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.
**Position is office based in either Columbia, SC; Florence, SC or Birmingham, AL ** Candidates mustreside currentlyin these areas to be considered.Required Education:
- Bachelors Degree - Nursing
Required Work Experience:
- Fiveyears of clinical and utilization review to includetwo years of supervisory or team lead experience or equivalent military experience in grade E4 or above.
Required Skills and 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.
Required License and Certificate:
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Equal Employment Opportunity StatementBlueCross 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 abilities@bcbssc.com or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.