Medical Review Supervisor

Overview

Internal Reference Number: R1049162

Summary:

Why should you join the Blue Cross Blue Shield of South Carolina family of companies? We are the largest insurance company in South Carolina, a leading administrator of government contracts, and operate one of the Southeast's most sophisticated data processing centers. We are a diverse family of subsidiary companies that enables us to build on multiple business strengths and deliver outstanding service to our customers.

This open position is within CGS Administrators, a subsidiary that provides administrative and business services to state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers. We are expanding our Medicare Part A Medical Review team focused on Prior Authorizations, adding five new staff to enhance service to Medicare recipients.

This position will lead a team of four to ten Medical Reviewers and supervise the daily functions of Utilization Review, Case Management, Medical Review staff, and specialty programs. It ensures appropriate levels of healthcare services are provided and manages team workload to meet processing and quality metrics. This is an administrative supervisory role requiring strong attention to detail, clinical and computer skills.

It is suited for someone who is a self-motivated leader with excellent time management, with no regular patient/provider contact. It is ideal for individuals seeking to transition from direct patient care. Typical schedule is Monday through Friday daytime with some flexibility; no regular weekends or holidays, supporting a good home/work life balance.

Position

Purpose:

Responsible for the supervision and maintenance of the daily operations of Utilization Review/Review Nurses, Case Management, Medical Review staff, and specialty programs, ensuring compliant, high-quality healthcare services and determinations are in accordance with corporate policies and Medicare guidelines.

CGS () – a Blue Cross Blue Shield of South Carolina subsidiary.

• Preferred candidate will live within 40 miles of Nashville, TN or Columbia, SC
  . If living in Nashville or Columbia, this will be an onsite position. A hybrid schedule may be considered.

• Superior candidates with preferred experience and skills will be considered for remote work. To work from home, you must have high-speed internet (non-satellite) and a private home office.

• Work hours are 8:00 am to 4:30 pm CT, Monday through Friday.

• Manages day-to-day activities for assigned staff.

• Identifies training needs and verifies accuracy and timeliness of workflow functions.

• Supervises staff including approval of time, leave, performance reviews, etc.

• Selects, trains, and motivates staff in providing excellent customer service with customers, marketing, management, and others.

• Performs quality control functions for work performed.

• Develops work plans to improve quality performance. Prepares, reviews, and maintains weekly/monthly reports.

• Develops, maintains, and updates procedures/documentation for conducting audits.

• Develops and communicates department standards and expectations of staff.

• Coordinates special projects, system testing enhancements, etc.

• Required Licenses and Certificates: Active, unrestricted RN licensure from the United States in the state of hire, or active compact multistate unrestricted RN license (NLC), or active, unrestricted licensure/certification in the state of hire in a required specialty area, or for Div. 75 only, active unrestricted licensure as social worker, counselor, or psychologist. For Divs. 55 and 75 only:
  Supervisors of Case Management must obtain CM certification within 3 years of hire.

• Required
  
  Education:
  
  Associate degree in a job-related field or graduate of an Accredited School of Nursing (Degree Equivalency: Graduate of Accredited School of Nursing).

• Required
  
  Work Experience:
  
  Five years clinical or five years utilization review/medical review experience (three of the five must be clinical). One year in a team lead/leadership role or equivalent military experience (grade E4 or…