Manager, Medical Review – Medicare Appeals, Utilization Review, Part A, HHH
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Hybrid
Location: Nashville • Tennessee • United States
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About the role
- Manages the medical review process
- Maintains a well-trained staff
- Develops/implements medical review strategy with the ultimate goal of reducing the error rate
- Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations
- Identifies missed standards and implements corrective actions
- Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action
- Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner
- Interfaces with internal and external customers such as appellants/attorneys, congressional offices , and other regulatory bodies as required to build and maintain positive customer relationships
Requirements
- Bachelor's degree in a job-related field
- 5 years clinical and utilization review to include 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above
- Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills
- Good judgment skills
- Proficient spelling, grammar, punctuation, and basic business math
- Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion
- Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Benefits
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewutilization reviewsupervisory experienceteam leadershipmedical review strategyerror rate reductioncompliance standardsfeedback provisionanalytical skillsbusiness math
Soft Skills
verbal communicationwritten communicationorganizational skillscustomer servicecritical thinkingpresentation skillsjudgment skillspersuasionnegotiationdiscretion
Certifications
Bachelor's degreeactive RN licensurecompact multistate RN license