RN Senior Medical Reviewer - CGS

CGS Administrators LLC; Columbia (SC); Remote; USD 60,000 - 100,000; Full time

Job summary

Join a forward-thinking company as a Senior Medical Reviewer, where you'll lead a team in providing high-quality healthcare services. This role offers the opportunity to utilize your clinical expertise and leadership skills while ensuring compliance and quality in medical reviews. With a commitment to outstanding service and innovative practices, you'll play a vital role in supporting healthcare providers and beneficiaries across the nation. Enjoy a flexible work-from-home arrangement and a comprehensive benefits package that promotes your well-being and professional growth.

Benefits

401(k) with company match

Health plans

Vision coverage

Life insurance

Paid leave

Holidays

On-site amenities

Wellness programs

Tuition assistance

Recognition programs

Qualifications

• Active RN licensure and strong clinical experience required.
• Excellent customer service and organizational skills essential.

Responsibilities

• Lead and train staff as a Senior Medical Reviewer.
• Monitor workflow and ensure adherence to quality plans.

Skills

Clinical Experience

Customer Service

Organizational Skills

Communication Skills

Analytical Skills

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

Database Software

Job description

SummaryWe are currently hiring for a Senior Medical Reviewer to join CGS, a Celerian Group Company and subsidiary of BlueCross BlueShield of South Carolina. In this role, you will act as a Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to the unit supervisor/manager through guidance, training, and direction to staff. You will also ensure that appropriate levels of healthcare services are provided.

CGS Administrators provides various services under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, healthcare providers, and medical equipment suppliers in 33 states, supporting over 20 million Medicare beneficiaries nationwide. We are committed to delivering outstanding service to our customers. If you share this philosophy, consider joining our team!

Interested in working for a growing company with an innovative outlook? Join us today!

Logistics

• CGS Administrators (cgsadmin.com), a subsidiary of BlueCross BlueShield of South Carolina.
• This is a full-time position (40 hours/week), Monday through Friday. This is a W@H opportunity and can be located anywhere within the U.S.

What You Will Do:

• Serve as a team leader and senior Medical Reviewer, providing leadership, guidance, and training to staff. Maintain knowledge of unit functions and interpret procedures for new hires, department workflows, and internal processes. Act as a resource for troubleshooting and resolving issues, keeping management informed of problems.
• Assist management in monitoring workflow and workloads, including reassigning work to meet deadlines, reporting, and addressing aging issues.
• Participate in departmental quality reviews, ensuring adherence to quality plans, and communicate feedback on medical review decisions and claims processing. Develop or revise quality instructions, forms, and documents as needed.
• Provide quality service and effective communication with internal and external customers, resolving discrepancies and problems by obtaining necessary information from various sources.
• Participate in compliance initiatives and oversee special projects as assigned by management.

To Qualify for This Position, You Will Need:

• Active, unrestricted RN licensure from the U.S. or in the state of hire, including multistate licensure as per the Nurse Licensure Compact, or equivalent licensure/certification in the specialty area.
• Associate Degree in Nursing or graduation from an accredited Nursing school.
• Four years of clinical experience, or two years clinical plus two years in medical/utilization review, or a combination of health plan, clinical, and business experience totaling four years.
• Strong knowledge of managed care, healthcare delivery systems, and clinical experience in home health, rehabilitation, or broad medical-surgical fields. Familiarity with criteria and protocols, proficiency in Word and Excel, and ability to work independently, prioritize, and make sound decisions.
• Excellent customer service, organizational, communication, and analytical skills, with the ability to handle confidential information and motivate others.
• Proficiency in Microsoft Office software.

Preferred Qualifications:

• Bachelor's degree in Nursing or equivalent.
• Knowledge of database software and Medicare.
• Proficiency in Excel, team-oriented, and self-motivated.

What We Offer:

• 401(k) with company match, health plans, vision coverage, life insurance, paid leave, holidays, on-site amenities, wellness programs, tuition assistance, recognition programs, incentive and merit plans, and continuing education funds.

Next Steps:

After applying, our recruiting team will review your resume, possibly conduct a brief interview, and select the most qualified candidates for interviews, with priority given to those with preferred qualifications.

EEO Statement:

BlueCross BlueShield of South Carolina and subsidiaries are committed to equal employment opportunities and affirmative action, promoting diversity and inclusion in the workplace. We provide reasonable accommodations for individuals with disabilities or religious needs. For assistance, contact [e-mail] or call 800-288-2227, ext. 47480. We participate in E-Verify and comply with pay transparency laws.