Summary
 

Analyzes medical review utilization data, researches new medical procedures or technology, and acts as a lead resource to providers and internal staff on issues concerning medical policies. Heavily involved in policy generation to include the development of new policy and the revision of old policy. This role is centered on policy expertise rather than organizational clinical leadership. While highly impactful, the scope is focused on Medicare policy development, interpretation, and guidance. It does not include enterprise clinical leadership, direct reports, or executive-level strategic ownership.

Description
 

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

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@H opportunity 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:

• Supports operations in the form of case review on both medical and regulatory matters. Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.

• Educates staff and medical community on various aspects of medical policy and program administration.

• May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies. Develops external relationships with the medical community and serves as liaison between these entities and the contractors.

• Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.

• Conducts research into new or controversial medical procedures and technology.

To Qualify for This Position, You Will Need:

• Required Education: Doctorate in a job-related field

• Required Licenses and Certificates: Active state medical license and current board certification in a recognized specialty.

• Required Work Experience: 5 years post graduate experience in direct patient care.

• Required Skills: Excellent verbal and written communication skills. Excellent customer service, organizational, and presentation skills. Good judgment skills. Proficiency in spelling, punctuation, and grammar. Ability to persuade, negotiate, or influence others. Ability to work as a team member as well as a leader. Knowledge of medical and utilization review techniques.

• Required Software: Microsoft Office.

What We Prefer:

• Highly inquisitive, Self-Starter

• Advanced problem solving skills

• Medicare Part A experience

• Strong client facing, relationship building skills

• Ability to follow the Scientific Method

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the ben