Provider Appeals Manager

BlueCross BlueShield of South Carolina•Columbia, SC

2d•Onsite

About The Position

Manages the successful operations of a department that is responsible for administering part of a Medicare service contract. Oversees all appeals and rebuttals activities and requirements outlined in the National Provider Enrollment (NPE) Statement of Work, and applicable sections of the Program Integrity Manual (PIM), ensuring adherence to administrative law principles and CMS regulatory requirements. Acts as a subject matter expert on appeal processes and decisions. Works closely with the Division of Provider Enrollment Appeals at CMS as well as the NPE Program Manager. Logistics: Palmetto GBA– one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located onsite at 17 Technology Circle, Columbia, SC, 29203. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. What You’ll Do: Provides management oversight of departmental staff and programs, ensuring operational consistency and regulatory alignment. Ensures compliance with CMS regulations, guidelines, and performance standards as well as maintaining internal controls, and mitigating compliance risk related to appeals. Provides general research and analysis on legal matters impacting appeal and rebuttal decisions made by the unit. Responsible for drafting standard legal verbiage to be used in correspondence. Partners with Legal, Compliance, and Operations to resolve multifunctional issues and ensure consistent application of CMS and administrative law requirements. Participates in special projects, including policy development, compliance reporting, and regulatory change implementation.

Requirements

Juris Doctorate or Master of Laws (LLM) degree from a law school accredited by the American Bar Association.
3 or more years of prior work experience in administrative law, three or more years of post-juris doctor (J.D.) and/or post-Master of Laws (LLM) experience in legal writing and research, and five or more years of prior supervisory/team lead experience in legal writing, legal research, and/or administrative law, experience can be concurrent.
Excellent verbal and written communication skills.
Excellent judgment, organizational, customer service, analytical/critical thinking skills.
Proficiency in grammar, spelling, and punctuation skills.
Basic business math proficiency.
Ability to handle confidential or sensitive information with discretion.
Working knowledge of word processing, spreadsheet software.

Responsibilities

Provides management oversight of departmental staff and programs, ensuring operational consistency and regulatory alignment.
Ensures compliance with CMS regulations, guidelines, and performance standards as well as maintaining internal controls, and mitigating compliance risk related to appeals.
Provides general research and analysis on legal matters impacting appeal and rebuttal decisions made by the unit.
Responsible for drafting standard legal verbiage to be used in correspondence.
Partners with Legal, Compliance, and Operations to resolve multifunctional issues and ensure consistent application of CMS and administrative law requirements.
Participates in special projects, including policy development, compliance reporting, and regulatory change implementation.