Senior Medical Review Director – Stop Loss

BlueCross BlueShield of South Carolina

Lead Medical Review and Prior Authorization programs for government healthcare at BlueCross BlueShield. Oversee program compliance, quality standards, and team development in a remote role.

Posted 4/25/2026full-timeRemote • Florida, North Carolina, South Carolina, Washington • 🇺🇸 United StatesSeniorWebsite

About the role

Key responsibilities & impact

Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for government programs
Directs and oversees the Medical Review and Prior Authorization programs ensuring performance expectations, compliance standards, workload issues, quality control, training and maintaining effective staffing levels and budgetary limits are maintained per the Center for Medicare and Medicaid Service (CMS) guidelines
Guides the Medical Review Team in the development and implementation of an efficient and effective Medical Review Strategy, including the integration of policy and education, that optimizes critical Medical Review cycle times
Serves as the Medical Review and Prior Authorization liaison between internal and external stakeholders
Ensure system/operational compliance with CMS directives
Establish, guide and analyze the effectiveness of Medical Review and Prior Authorization operations against benchmarks that are developed as measures of success
Analyze performance trends and develop new/modified work processes to improve overall operations quality/timeliness/customer satisfaction/financial outcomes
Direct/develop/evaluate/motivate subordinates to achieve and maintain production and quality standards ensuring area review decisions are accurate and all associates are well informed and trained on contract process work instructions
Directs and oversees the development of the Medical Review and Prior Authorization Program strategy and error rate reduction plans based on the findings
Develop and implement the Medical Review Programs strategic plan with goals supportive of the corporate strategic plan
Manage budget to ensure cost effectiveness and performance quality
Serve as the liaison and maintain proactive working relationship with CMS and other Medicare program leadership as needed by contract
Investigate and resolve action items assigned by executive management
Resolve priority level problems from providers, beneficiaries, and CMS

Requirements

What you’ll need

Bachelor's in a job related field
10 years healthcare program management, utilization/case management, or medical review management or equivalent military experience in grade E4 or above
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
Ability to evaluate existing processes and develop ways to streamline procedures
Strong organizational, analytical, communication, and decision-making skills
Knowledge of budget preparation and management
Ability to handle difficult situations
Ability to easily adapt to change
If RN, active RN licensure in state hired.

Benefits

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

healthcare program managementutilization managementcase managementmedical review managementbudget preparationprocess evaluationquality controlperformance analysisstrategic planningerror rate reduction

Soft Skills

communication skillsorganizational skillscustomer service skillsanalytical skillscritical thinking skillspresentation skillsjudgment skillspersuasion skillsnegotiation skillsadaptability

Certifications

Bachelor's degreeactive RN licensure