RN Senior Medical Reviewer - CGS

BlueCross BlueShield of South Carolina; United States; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Senior Medical Reviewer to lead specialty programs and ensure quality healthcare services. In this full-time remote position, you will guide a team, monitor workflows, and participate in quality reviews while providing exceptional service to clients. This role offers a chance to make a significant impact in healthcare delivery, supporting millions of beneficiaries across the nation. Join a company that values innovation and a commitment to excellence, and enjoy a range of benefits including retirement plans, health coverage, and opportunities for professional growth.

Benefits

401(k) retirement savings plan with company match

Subsidized health plans

Life insurance

Paid annual leave

Nine paid holidays

On-site cafeterias and fitness centers

Wellness programs

Tuition assistance

Service recognition

Continuing education funds

Qualifications

• Active RN licensure required, or equivalent licensure in specialty area.
• Four years clinical experience or equivalent combination of experience.

Responsibilities

• Lead and train staff in medical review and case management areas.
• Monitor workflow and ensure quality service to internal and external customers.

Skills

Managed Care Knowledge

Clinical Experience

Analytical Skills

Customer Service Skills

Communication Skills

Leadership Skills

Decision Making

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing

Tools

Microsoft Office

Database Software

Job description

Summary

We 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 Team Lead 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. You will also ensure appropriate levels of healthcare services are provided.

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!

Description

Logistics

• CGS Administrators (cgsadmin.com), - one of BlueCross BlueShield's South Carolina subsidiary companies.
• This position is full time (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:

• 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 inner workings 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 combination of health plan, clinical, and business experience totaling 4 years.

• Required Skills: Working knowledge of managed care and various forms of health care 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:

• Bachelor's degree- Nursing or Graduate of Accredited School of Nursing.
• Knowledge of database software.
• Knowledge of Medicare.
• Proficient in Excel.
• Team player.
• Self-starter.

What We Can Do for You:

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.

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 a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualified candidates, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail [e-mail] or call 1-800-288-2227, 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.

About the company

When you hear "BlueCross BlueShield of South Carolina," you'll see people nodding in recognition. Most everyone knows who we are. As the only South Carolina-owned and operated health insurance carrier, we have been offering security to Palmetto State citizens for more than 70 years. We are also one of South Carolina's largest employers.