Job Description

# # # To learn more about our website privacy policy, click on this .* - 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.* 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.* **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.* Bachelors degree in nursing or Graduate of Accredited School of Nursing.* Ability to conduct second-level medical reviews of appeals and the ability to prepare comprehensive ALJ (Administrative Law Judge) position papers for hearings.* Advanced knowledge of Medicare Local Coverage Determinations (LCDs), and related policies to ensure compliance and accuracy in all determinations.* Strong analytical, writing, and communication skills are essential, along with the ability to work independently and manage multiple priorities under strict deadlines.* Two years clinical and two years medical review/utilization review.* Previous DME Medical Review experience.* Proficient in Excel.* Team player and Self-starter.* 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

#J-18808-Ljbffr

Job Tags

Similar Jobs