Registered Nurse Senior Medical Reviewer (Medicare Part B) - CGS

CGS Administrators LLC; California (MO); Remote; USD 57,000 - 111,000; Full time

Job summary

A healthcare company is seeking a Registered Nurse Senior Medical Reviewer to lead a team in medical review and utilization management. The role involves ensuring quality healthcare services and assisting management with departmental operations. Candidates must have an active RN license, an associate degree in nursing, and four years of related clinical experience. This full-time position allows remote work anywhere in the U.S. Competitive salary and benefits are offered.

Benefits

Subsidized health plans

401k retirement plan with company match

Paid time off

Education assistance

Qualifications

• Active, unrestricted RN licensure from the United States.
• Four years clinical or two years clinical and two years medical review.
• Knowledge of managed care and healthcare delivery systems.

Responsibilities

• Act as team lead for medical review and utilization management.
• Monitor workflow and manage workloads effectively.
• Participate in compliance initiatives and quality reviews.

Skills

Strong clinical experience

Analytical or critical thinking skills

Good judgment skills

Customer service skills

Ability to handle confidential information

Education

Associate Degree - Nursing

Tools

Microsoft Office

Job description

Overview

We are currently hiring for a Registered Nurse Senior Medical Reviewer to join CGS, a Celerian Group Company and subsidiary of BlueCross BlueShield of South Carolina. The team the position will work on handles Medicare Part B claims. In this role you will act as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to manager by giving direction/guidance/training to staff. You will also ensure appropriate levels of healthcare services are provided. This is a computer-based position with no member/patient interaction.

CGS Administrators provides a variety of services under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, health care providers, and medical equipment suppliers in 33 states, supporting the needs of more than 20 million Medicare beneficiaries nationwide. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Want to work for a growing company with an innovative eye towards the future? Join us today!

Logistics

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

Location: This position is full time (40 hours/week) Monday through Friday. This is a W@Hopportunity and can be located anywhere within 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 source 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 all 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 a 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 make 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 lead/direct/motivate others.
• Required Software: Microsoft Office.

What We Prefer

• Prior experience in Part B Medical Review, Appeals, Utilization Review or Quality Assurance strongly preferred.
• Five years of varied clinical RN experience in critical care, emergency, inpatient medical/surgical, and/or DME (Durable Medical Equipment).
• Medicare Part B experience.
• Proficient in Excel
• Team player
• Self-starter

Benefits

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.

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.

Pay Range Information

Range Minimum $57,790.00

Range Midpoint $84,089.00

Range Maximum $110,388.00

Pay Transparency Statement: This range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

Equal Employment Opportunity

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. 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 [e-mail] 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.