Manager, Medical Review (Medicare - Appeals; Utilization Review; Part A; HHH)

BlueCross BlueShield of South Carolina•Nashville, SC

1d•Hybrid

About The Position

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, while helping to manage and hold the team accountable for quality standards within their work. Manages and oversees the accurate processing of claims deferred for medical necessity review, ensuring adherence to nationally recognized standards as well as local, state, and federal regulations. Drives continuous improvement by identifying and implementing process enhancements, while supporting team accountability and maintaining high-quality performance standards. Logistics: CGS (cgsadmin.com) – one of BlueCross BlueShield of South Carolina’s subsidiary companies. Location: T his is a full-time position (40 hours per week), Monday through Friday, based in a collaborative office environment during standard business hours of 8:00 AM to 5:00 PM. The primary work location is 26 Century Blvd., Suite ST610, Nashville, TN 37214. Depending on business needs and individual circumstances, remote or hybrid work arrangements may be available for qualified and interested candidates.

Requirements

Bachelor's degree in a job-related field.
5 years clinical and utilization review to include 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.
Microsoft Office.
Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Nice To Haves

Demonstrated expertise in Medicare claim reviews (Appeals, Utilization Review, Part A, HHH), and a thorough understanding of Medicare policies/coverages/regulations.
Demonstrated experience leading teams of 15–20 professionals across clinical and non-clinical functions, with a consistent focus on maintaining high-quality standards.
Strong commitment to continuous process improvement and operational efficiency.
Proven experience managing.

Responsibilities

Manages the medical review process.
Maintains a well-trained staff.
Develops/implements medical review strategy with the ultimate goal of reducing the error rate.
Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations.
Identifies missed standards and implements corrective actions.
Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action.
Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner.
Interfaces with internal and external customers such as appellants/attorneys, congressional offices , and other regulatory bodies as required to build and maintain positive customer relationships.