Medical Review Manager

ourhrconnect; Myrtle Beach (SC); On-site; USD 90,000 - 130,000; Full time

Job summary

BlueCross BlueShield of South Carolina is seeking a Medical Review Manager to oversee the processing of claims deferred for medical necessity review, ensuring compliance with federal, state, and local laws. You will identify improvement opportunities and lead a trained staff in a full-time on-site role in Myrtle Beach, SC.

The position requires RN licensure, 5 years of clinical/utilization review experience with 2 years of supervisory or leadership duties, and strong communication and analytical

Qualifications

• Associate's degree in a related field; Bachelor's degree required for Celerian Group
• RN licensure active in state hired; multistate compact license may apply
• 5 years clinical and utilization review experience including 2 years supervisory or team lead, or equivalent military grade
• Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills
• Good judgment, discretion with confidential information, and strong spelling/grammar/business math
• Knowledge of government programs and guidelines, medical/legal terminology, disease management and litigation processes
• Proficiency with Microsoft Office; TRICARE experience preferred

Responsibilities

• Manages the medical review process.
• Maintains a well-trained staff.
• Develops/implements medical review strategy to reduce error rates.
• Ensures timeliness of review, quality of decisions, productivity, and legal compliance.
• Identifies missed standards and implements corrective actions.
• Provides feedback to providers regarding results and corrective actions.
• Investigates inquiries and responds timely and accurately.
• Interfaces with appellants, attorneys, congressional offices, and regulators to maintain relationships.

Skills

Verbal communication

Written communication

Organizational skills

Customer service

Analytical thinking

Presentation skills

Judgment

Spelling/grammar

Business math

Persuasion/negotiation

Handling confidential information

Knowledge of gov programs

Education

Associate degree

Bachelor's degree

Nursing degree (RN/licensure)

Tools

Microsoft Office

Job description

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.

Description

Why should you join the BlueCross BlueShield of South Carolina 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 contracts. 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 our team!

Position Purpose:

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.

Logistics:

https://corporate.palmettogba.com/ - one of BlueCross BlueShield of South Carolina's subsidiary companies.

Location:

This position is full-time (40-hours/week) Monday-Friday from 8:00am-5:00pm and will be on-site in Myrtle Beach, SC.

What You'll 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.

To Qualify for This Position, You'll Need the Following:

• Required Education: Associate's in a job related field (Bachelor's degree required for the Celerian Group).
• Degree Equivalency: Graduate of Accredited School of Nursing (Equivalency not applicable for the Celerian Group or Palmetto GBA. Bachelor's degree required.)
• Required Work Experience: 5 years clinical and utilization review to include 2 years 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 Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

What We Prefer You to Have:

• Previous TRICARE experience

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

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