Summary
 

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.

Description
 

Logistics:

• This position is full-time (40 hours/week) daytime position Monday-Friday in a typical office environment.  It may be necessary, given the business need, to work outside these hours.

• The department works with IRF (Inpatient Rehabilitation Facility) and RCD (Review Choice Demonstration)

• To work from home, you must have high-speed (non-satellite) internet and a private home office.

• May required meetings or trainings in Columbia, SC.

What You’ll Do:

• You’ll be focused on proactively overseeing the accurate processing of claims that have been deferred for medical review.

• You will guide your team to review medical records and to ensure compliance with nationally recognized standards, and local, state, and federal laws and regulations.

• Accurately identifying and implementing process improvements and opportunities is vital for the success of this role. You are the subject matter expert for this role.

• Through the leadership of your team and recommendations to executive management, you will bring forward recommendations, feedback, process improvements, and assistance with special projects to make positive changes for the department/company.

To Qualify for This Position, You’ll Need:

• Required Licenses and Certificates: Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

• Education: A Bachelor’s Degree - Nursing or related field.

• Experience: Five (5) years clinical and utilization review to include two or more years supervisory or team lead experience or equivalent military experience in grade E4 or above.

• Skills/Abilities: 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.

• Required Software and Tools: Microsoft Office.

We Prefer That You Have:

• Experience: Prefer experience with RCD or a Clinical Start Up Program.

• Skills/Abilities: Knowledge of Medicare payment systems (FISS)/processing procedures for Medical Review. Understanding of clinical/medical data. Demonstrates ability to deal with ambiguity and turn plans into action. Ability to present to/train individuals and groups on complex information.

• Software and Tools: Intermediate Excel knowledge. FISS, EMS, or iFLOW experience.

What We Can Do for You:

• 401(k) retirement savings plan with company match.

• Subsidized health plans and free vision coverage.

• Life insurance.

• Paid annual leave – the longer you work here, the more you earn.

• Nine paid holidays.

• On-site cafeterias and fitness centers in major locations.

• Wellness programs and healthy lifestyle premium discount.

• Tuition assistance.

• Service recognition.

• Incentive Plan.

• Merit Plan.

• Continuing education funds for additional certifications and certification renewal.

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 disabilities and 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.com or 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.

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