Medical Review Director - CGS Administrators, LLC

Summary

Why should you join the Blue Cross Blue Shield of South Carolina family of companies? Other companies come and go, but for more than seven decades we've been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina and a leading administrator of government contracts, operating one of the most sophisticated data processing centers in the Southeast.

We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths and deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

The Medical Review Director directs and oversees operations in the medical review, clinical pricing, and re‑determination areas ensuring performance expectations, compliance standards, and budgetary limits are maintained. In this role, you will supervise and motivate area employees.

• Oversee operations of assigned areas and coordinate tactical team activities.
• Ensure area review decisions are accurate and all associates are well informed and trained on contract process work instructions.
• Review and analyze data and create departmental strategy and error‑rate reduction plans based on findings.
• Provide guidance on the analysis, identification, and corrective actions of services and/or providers with suspected abuse of the program.
• Work closely with the Provider Service Center and other internal departments, providing necessary assistance and resources to ensure consistency and achieve the integrated goals of reducing the claims payment error rate and procurement of additional contracts.
• Develop and monitor the budget for all assigned areas.

• Required
  
  Education:
  
  Bachelor’s in a job‑related field.
• Required Experience:
  • 5 years healthcare program management, utilization/case management, or medical review management.
  • 3 years of supervisory/management experience or equivalent military experience in grade E4 or above.
• Required Software and Tools:
  • Microsoft Office.
  • Knowledge of medical systems software.
• Required
  
  Skills and Abilities:
  • 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.

• Bachelor's degree – Nursing
• Graduate of accredited school of nursing
• Experience working with CMS and/or Medicare
• Working knowledge of Medicare claims processes and the Medicare program
• Strong understanding of using data to make business decisions
• Knowledge/understanding of utilization review guidelines, managed care delivery systems
• Ability to work independently, prioritize effectively, and make sound decisions
• Demonstrated presentation skills to work effectively with both internal and external customers
• Ability to handle confidential or sensitive information with discretion
• Ability to direct, motivate, and assess performance of others

Active RN licensure in state hired.

Typical office environment. Frequent travel between office buildings and occasional out‑of‑town travel. This role can be physically located in Nashville, TN;
Columbia, SC; or Springfield, IL. There is no option for remote or hybrid work schedules.

• Subsidized health plans, dental and vision coverage
• 401(k) 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

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

After submitting your application, our recruiting team members will…