Medical Review Director - CGS Administrators, LLC

Logistics: CGS Administrators, LLC - one of BlueCross BlueShield of South Carolina's subsidiary companies.

Location: This position is full-time (40-hours/week) Monday-Friday ONSITE in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role can be physically located in Nashville, TN, Columbia, SC, or Springfield, IL. There are no options for remote or hybrid work schedules.

Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

What You'll Do:

• Oversees operations of assigned areas. 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 areas.

To Qualify For This Position, You'll Need The Following:

• Required Education: Bachelor's in a job related field.

• Required Experience:

  • 5 years healthcare program management, utilization/case management, or medical review management.

  • 3 years of supervisory/management experience or equivalent military experience in grade E4 or above.

• Required Software and tools:

  • Microsoft Office.

  • Knowledge of medical systems software.

• 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 That You Have The Following:

• Bachelor's degree - Nursing

• Graduate of Accredited School of Nursing

• Experience working with CMS and/or Medicare.

• Working knowledge of Medicare claims processes and the Medicare program.

• Strong understanding of using data to make business decision.

• Knowledge/understanding of utilization review guidelines, managed care delivery systems.

• Ability to work independently, prioritize effectively, make sound decisions.

• Demonstrated presentation skills in order to work effectively with both internal and external customers.

• Ability to handle confidential or sensitive information with discretion.

• Ability to direct, motivate, and assess performance of others.

Preferred Licenses and Certificates: Active RN licensure in state hired.

Work Environment: Typical office environment frequent. Travel between office buildings. Some out of town travel.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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 $76,546.00

Range Midpoint $113,900.50

Range Maximum $151,255.00

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 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 individuals with disabilitiesand 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.comor 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.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's moreinformation.

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