Coordinator, Medical Affairs

BlueCross BlueShield of South Carolina • Nashville, TN

2d • Hybrid

About The Position

This role serves as the primary point of contact for all activities related to the Administrative Law Judge (ALJ) program. This includes medical record review, policy analysis and interpretation, preparing other ALJ team members for hearings, writing position papers for submission to the court, and testifying on behalf of CGS and the Medicare Program. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. This position provides clinical expertise, research, and judgment to develop Local Coverage Determinations (LCDS) under the direction of medical director. Maintains LCDS once developed. Educates providers and internal customers on LCDS. Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance. Provides clinical input for internal requests. Serves as reviewer to determine inter-rater reliability.

Requirements

• Bachelor's in a job related field
• Associate's degree in Nursing with an active RN license.
• 5 years clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.
• Knowledge of managed care or medical claims payment policy issues.
• Working knowledge of word processing, spreadsheet software.
• Excellent verbal and written communication skills.
• Excellent customer service, organizational, presentation, analytical or critical thinking skills.
• Ability to persuade, negotiate, or influence others.
• Ability to handle confidential or sensitive information with discretion.
• Sound clinical review judgement.
• Independent thinking and strong organizational skills.
• Microsoft Office.
• An active, unrestricted RN license from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• For Division 33, Certified Genetic Counselor will be considered in lieu of RN License.
• Ability to obtain a security clearance.
• Must be a U.S. Citizen.

Nice To Haves

• Bachelor's degree- Nursing.
• 7 years-clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.
• Working knowledge of database software.
• Knowledge of government/healthcare programs and contracts laws, regulations.
• Knowledge of government/healthcare programs and regulations, coding, and approval practices.
• Knowledge of corporate administrative/medical policy for all lines of business.
• Knowledge of guidelines, benefits, and coverage for all lines of business.
• Working knowledge of Microsoft Access or other database software, DB2 and Easytrieve.
• HIAA, CCM, MPH, MHA certifications.

Responsibilities

• Serves as the primary point of contact for all activities related to the Administrative Law Judge (ALJ) program.
• Conducts medical record review.
• Performs policy analysis and interpretation.
• Prepares other ALJ team members for hearings.
• Writes position papers for submission to the court.
• Testifies on behalf of CGS and the Medicare Program.
• Provides clinical expertise, research, and judgment to develop Local Coverage Determinations (LCDS) under the direction of medical director.
• Maintains LCDS once developed.
• Educates providers and internal customers on LCDS.
• Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance.
• Provides clinical input for internal requests.
• Serves as reviewer to determine inter-rater reliability.

Benefits

• 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
• Continuing education funds for additional certifications and certification renewal.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level