Manager, Medical Review – Medicare, Appeals, Utilization Review, Part A, HHH

CGS Administrators, LLC

Manager overseeing medical review processes for Medicare claims at BlueCross BlueShield of South Carolina. Ensuring compliance with standards and laws while driving continuous improvement in claim processing.

Posted 4/18/2026full-timeNashville • South Carolina, Tennessee • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Oversees the accurate processing of claims that have been deferred for medical necessity review
Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations
Identifies and implements process improvement opportunities
Manages and oversees the accurate processing of claims deferred for medical necessity review
Drives continuous improvement by identifying and implementing process enhancements
Supports team accountability and maintains high-quality performance standards
Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required

Requirements

What you’ll need

Bachelor's degree in a job-related field
5 years clinical and utilization review including 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

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

clinical reviewutilization reviewprocess improvementmedical necessity reviewdisease managementlitigation processesanalytical skillspresentation skillsbusiness math

Soft Skills

communication skillsorganizational skillscustomer service skillscritical thinkingjudgment skillspersuasionnegotiationinfluencediscretion

Certifications

Bachelor's degreeactive RN licensurecompact multistate RN license