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Registered Nurse Senior Medical Reviewer (Medicare Part B) - CGS
Overview
We are currently hiring for a Registered Nurse Senior Medical Reviewer to join CGS, a Celerian Group Company and subsidiary of BlueCross BlueShield of South Carolina. The team handles Medicare Part B claims. In this role you will act as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and guidance to the manager through direction and training of staff. You will also ensure appropriate levels of healthcare services are provided. This is a computer-based position with no member/patient interaction.
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!
Logistics
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
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 healthcare 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
Prior experience in Part B Medical Review, Appeals, Utilization Review or Quality Assurance strongly preferred.
Five years of varied clinical RN experience in critical care, emergency, inpatient medical/surgical, and/or DME (Durable Medical Equipment).
Medicare Part B experience.
Proficient in Excel
Team player
Self-starter
Our Comprehensive Benefits Package Includes The Following
Subsidized health plans, dental and vision coverage
401k retirement savings plan with company match
Life Insurance
Paid Time Off (PTO)
On-site cafeterias and fitness centers in major locations
Education Assistance
Service Recognition
National discounts to movies, theaters, zoos, theme parks and more
What We 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.
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.
Pay Range Information
Range Minimum $ 57,790.00
Range Midpoint $ 84,089.00
Range Maximum $ 110,388.00
Pay Transparency Statement: Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.
Equal Employment Opportunity
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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 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.
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