Summary
 

Acts 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. Ensures appropriate levels of healthcare services are provided.

**This position is apart of the End-Stage Renal Disease QIP Contract.***

Description
 

Logistics: Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

• Functions as a team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains a working knowledge of unit functions and the ability to interpret to new hires, department interworking, and workflow. Acts as a 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 a 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.

Required Education:

• Associate Degree - Nursing OR
• Graduate of Accredited School of Nursing.

Required Work Experience:

• Four years of clinical, OR
• Two years of clinical and two years of medical review/utilization review, OR
• Combination of health plan, clinical, and business experience totaling four years.

Preferred requirements

• ESRD/renal dialysis experience

• Five or more years’ clinical, quality management, or leadership experience as a registered nurse in a Dialysis setting.

• Three or more years’ education/training/consulting experience related to Dialysis services. (may be concurrent).
• Three or more years’ experience in quality management coordination related to Dialysis services. (may be concurrent)

Required Skills and Abilities:

• Working knowledge of managed care and various forms of health are 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 and Tools:

• Microsoft Office.

Required License and Certificate:

• 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).

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to pro