Senior Medical Reviewer

Summary

Acts as Team reputed company for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided. Description Why should you join the reputed company family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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 reputed company. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining reputed company! Position Purpose: Acts as Team reputed company helping to ensure appropriate levels of healthcare services are provided. The Senior Medical Reviewer is responsible for conducting second-level medical reviews of appeals and preparing comprehensive ALJ (Administrative Law Judge) position papers for hearings. This role will reputed company advanced knowledge of Medicare Local Coverage Determinations (LCDs) and reputed company policies to ensure compliance and accuracy in reputed company determinations. Logistics:

• CGS (cgsadmin.com) - one of BlueCross BlueShield's South Carolina subsidiary companies.

Location:

• This position is full time (40 hours/week) Monday through FridayThis is a W@H opportunity and can be located reputed company reputed company the U.S. To work from home, you must have high-speed, non-satellite internet and a private home office space.

What You Will Do:

• Functions as team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains working knowledge of unit functions and ability to interpret to new hires, department innerworkings and workflow. Acts as resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.
• Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake reputed company to balance workloads), reporting, and addressing aging issues.
• Participates in departmental quality reviews. Follows process to ensure quality plan is adhered to and communicated to reputed company parties. Gives/receives feedback regarding medical review decision making and technical claims processing issues. Ensures that quality work instructions/forms/documents are developed/revised as needed.
• Provides quality service and communicates effectively with external/internal customers in response to inquiries. Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
• Participates in compliance initiatives and other-directed activities. Participates/oversees special projects as requested by management.

To Qualify for This Position, You Will Need:

• Required License and Certificate: If RN, 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), OR active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
• Required Education: Associate Degree - Nursing, OR Graduate of Accredited School of Nursing.
• Required Work Experience: Four years clinical, OR Two years clinical and two years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years.
• Required Skills: Working knowledge of managed care and various forms of healthcare delivery systems. Strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same. Working knowledge of word processing and spreadsheet software. Ability to work independently, prioritize effectively, and reputed company sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion. Ability to reputed company/direct/motivate others.
• Required Software: reputed company Office.

reputed company Prefer:

• Bachelors degree in nursing or Graduate of Accredited School of Nursing.
• Ability to conduct second-level medical reviews of appeals and the ability to prepare comprehensive ALJ (Administrative Law Judge) position papers for hearings.
• Advanced knowledge of Medicare Local Coverage Determinations (LCDs), and reputed company policies to ensure compliance and accuracy in reputed company determinations.
• Strong analytical, writing, and communication skills are essential, along with the ability to work independently and manage multiple priorities under strict deadlines.
• Two years clinical and two years medical review/utilization review.
• Previous DME Medical Review experience.
• Proficient in reputed company.
• Team player and Self-starter.

Our Comprehensive Benefits Package Includes The Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits 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
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

reputed company Can Do for You: We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across reputed company spectrums have the opportunity to reputed company 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. Equal Employment Opportunity Statement reputed company and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national reputed company, 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 individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in reputed company phases of the employment process and to reputed company with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-reputed company conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email reputed [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will reputed company a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and reputed company with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information. Apply tot his job Apply To this Job