Medical Review Supervisor

CGS Administrators•Nashville, TN

6d•Hybrid

About The Position

This open position is within one of our subsidiary companies called CGS Administrators. 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. While other companies are seeing a downturn, we are adding to our staff in strategic areas such as our Medicare Part A Medical Review team focusing on Prior Authorizations. We are adding five new staff to this team to provide better service to Medicare recipients. This position will lead a team of four to ten Medical Reviewers. Responsible for the supervision and maintenance of the daily functions of Utilization Review, Case Management, and/or Medical Review staff and specialty programs. Ensures appropriate levels of healthcare services are provided. Will manage the team workload to ensure processing and quality metrics are met. This administrative supervisory role will need strong attention to detail, clinical and computer skills. It will be best for someone who is a self-motivated leader that has excellent time management skills. No regular patient/provider contact. Excellent for those individuals looking to transition their career from the physical and time demands of direct patient care. The Monday through Friday daytime schedule with some flexibility, no regular weekends or holidays, provides the opportunity for 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. Logistics: CGS (cgsadmin.com) – one of BlueCross BlueShield of South Carolina’s subsidiary companies. Location: 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. Hybrid schedule may be considered. Superior candidates with preferred experience and skills will also be considered. These candidates will work from home, if selected. 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.

Requirements

Active, unrestricted RN licensure 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), OR, active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area, OR for Div. 75 only, active, unrestricted licensure as social worker, counselor, or psychologist from the United States and in the state of hire.
For Divs. 55 and 75 only: Supervisors of Case Management must obtain CM certification within 3 years of hire.
Associates in a job-related field OR graduate of Accredited School of Nursing.
Graduate of Accredited School of Nursing
Five years clinical OR five years utilization review/medical review experience (Three of the five must be clinical).
One year team lead/leadership role or equivalent military experience in grade E4 or above (may be concurrent with the five years).
Working knowledge of word processing, spreadsheet, and database software.
Ability to work independently, prioritize effectively, and make sound decisions.
Working knowledge of managed care and/or various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience.
Knowledge of specific criteria/protocol sets and the use of the same.
Good judgment skills.
Demonstrated customer service, organizational, and presentation skills.
Demonstrated proficiency in spelling, punctuation, and grammar skills.
Ability to persuade, negotiate, or influence others.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Ability to lead, motivate, and assess performance of others.
Microsoft Office.

Nice To Haves

Solid experience with and knowledge of Medicare Regulations.
Five years clinical experience as a Registered Nurse in the following specialty area(s): Outpatient Surgical, Pain Management, Cosmetic Surgery, Prior Authorization, Medical Review, Medicare Part A or Utilization Management.
Experience with HOPD ( Hospital Outpatient Department ) and Prior Authorization of RSNAT (Repetitive, Scheduled Non-Emergent Ambulance Transport).
Ability to work with multiple windows-based programs simultaneously.
Developing and using validation reports.
Intermediate Word, Excel and Outlook skills.

Responsibilities

Manages day-to-day activities for assigned staff.
Identifies training needs and verifies accuracy and timeliness of workflow functions.
Supervises staff to include approval of time, leave, performance reviews, etc.
Selects/trains/motivates staff in providing excellent customer service with customers, marketing, management/others.
Performs quality control functions for work performed.
Develops work plans to improve quality performance.
Prepares/reviews/maintains weekly/monthly reports.
Develops/maintains/updates procedures/documentation for conducting audits.
Develops/communicates department standards and expectations of staff.
Coordinates special projects, system testing enhancements, etc.