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 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 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 are delivery systems.  Strong clinical ex