Medical Review Director
Medical Review Director
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Job Description
Summary
Why should you join CGS Administrators and the BlueCross BlueShield of South Carolina family of companies Other companies come and go but for more than seven decades weve been part of the national landscape. BlueCross BlueShield of South Carolina is one of the nations leading administrators of government contracts and operates one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies including CGS Administrators that allows us to build on a variety of business strengths. 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!
Position Purpose:
As the Director of the DME Medical Review department you will oversee the operations of a dynamic team of approximately 150 dedicated clinical and nonclinical professionals. With primary responsibility for the following:
Operational Oversight: Ensuring smooth and efficient daytoday operations within the department
Team Leadership: Guiding and mentoring a diverse team to achieve their full potential.
Performance Management: Setting and monitoring performance expectations to drive excellence.
Compliance Assurance: Upholding stringent compliance standards to meet regulatory and customer contractual requirements.
Financial Stewardship: Strategically managing resources to achieve financial objectives and sustain departmental growth.
Description
Logistics:
This position is fulltime 40 hours/week 8 hours/day) Monday Friday ONSITE at One Century Plaza (OCP) Nashville TN or the Government Programs Complex (GPC) Columbia SC
What Youll Do:
Oversees operations of assigned area.
Coordinates tactical team activities.
Ensures area review decisions are accurate and all associates are well informed and trained on contract process work instructions.
Reviews and analyzes data and creates departmental strategy and error rate reduction plans based on the findings.
Provides guidance on the analysis identification and corrective actions of services and/or providers with suspected abuse of the program.
Works closely with the Provider Service Center and other internal departments providing necessary assistance and resources to ensure consistency and achieve the integrated goals of reducing the claims payment error rate and procurement of additional contracts.
Develops and monitors budget for all assigned area.
To Qualify for This Position Youll Need:
Required Education: Bachelors degree Business Administration Healthcare Administration Nursing or other related field.
Required Work Experience: 5 years healthcare program management utilization/case management or medical review management to include 3 years of supervisory/management experience or equivalent military experience in grade E4 or above.
Required Software and Tools:
Ability to use standard office equipment.
Knowledge of word processing spreadsheet and database software.
Knowledge of medical management systems.
Required Skills and Abilities:
Excellent verbal and written communication skills.
Excellent organizational customer service analytical or critical thinking skills.
Excellent presentation skills.
Good judgment skills.
Ability to persuade negotiate or influence others.
We Prefer You to Have:
Strong Microsoft Office Skills
Processoriented work style
RN license STRONGLY PREFERRED
Knowledge of Medicare contracting/Medicare policy/regulations/DME
Excellent decision making and problem solving.
Datacentric ability to understand and make decisions based on data trends
Demonstrated knowledge of developing monitoring and overseeing budgets.
8 yearshealthcare program management utilization/case management or medical review management to include 3 years of supervisory/management experience or equivalent military experience grade E4 or above.
What Blue Can Do for You:
We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills advance their careers and contribute their unique abilities to the growth of our company.
Our comprehensive benefits package includes:
Subsidized health plans dental and vision coverage
401K retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
Onsite cafeterias and fitness centers in major locations
Wellness program and healthy lifestyle premium discount
Tuition assistance
Service recognition
Employee Assistance
Discounts to movies theaters zoos theme parks and more
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 our recruiter to verify resume specifics and salary requirements.
Management will be conducting interviews with those candidates who qualify with prioritization given to those candidates who demonstrate the preferred qualifications.
We participate in EVerify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Heresmore 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 email or callext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a casebycase basis.
We participate in EVerify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Heresmore 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 email or callext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a casebycase basis.
Required Experience:
Director
Employment Type
Full-Time
