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.

Description

Logistics: Palmetto GBA – one of BlueCross BlueShield’s South Carolina subsidiary companies.

This role begins with onsite training. After training is completed, the position requires three days per week onsite at either of the following locations:
• 17 Technology Circle, Columbia, SC 29203
• 3700 Colonnade Parkway, Birmingham, AL 35243

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.

Required Education:

• Bachelors Degree in Nursing

Required Work Experience:

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

Preferred Experience:

• Medicare Part B experience.
• CPC training/certification.
• ESRD experience.

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).

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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related 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 [email protected] or call 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.

We participate in E-Verify and comply 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.