RN Senior Medical Reviewer - ALJ Clinician

CGS Administrators•Nashville, TN

18d•Remote

About The Position

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: Acts as Team Lead helping to ensure appropriate levels of healthcare services are provided. The Senior Medical Reviewer is responsible for conducting second-level medical reviews of appeals and preparing comprehensive ALJ (Administrative Law Judge) position papers for hearings. This role will leverage advanced knowledge of Medicare Local Coverage Determinations (LCDs) and related policies to ensure compliance and accuracy in all determinations. Logistics: CGS (cgsadmin.com) - one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full time (40 hours/week) Monday through Friday . This is a W@H opportunity and can be located anywhere within the U.S. To work from home, you must have high-speed, non-satellite internet and a private home office space.

Requirements

If RN, 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.
Associate Degree - Nursing, OR Graduate of Accredited School of Nursing.
Four years clinical, OR Two years clinical and two years medical review/utilization review, OR , combination of health plan, clinical, and business experience totaling 4 years.
Working knowledge of managed care and various forms of healthcare 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.
Working knowledge of word processing and spreadsheet software.
Ability to work independently, prioritize effectively, and make sound decisions.
Good judgment skills.
Demonstrated customer service, organizational, and presentation skills.
Demonstrated proficiency in spelling, punctuation, and grammar skills.
Demonstrated oral and written communication 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/direct/motivate others.
Microsoft Office.

Nice To Haves

Bachelors degree in nursing or Graduate of Accredited School of Nursing.
Ability to conduct second-level medical reviews of appeals and the ability to prepare comprehensive ALJ (Administrative Law Judge) position papers for hearings.
Advanced knowledge of Medicare Local Coverage Determinations (LCDs), and related policies to ensure compliance and accuracy in all determinations.
Strong analytical, writing, and communication skills are essential, along with the ability to work independently and manage multiple priorities under strict deadlines.
Two years clinical and two years medical review/utilization review.
Previous DME Medical Review experience.
Proficient in Excel.
Team player and Self-starter.

Responsibilities

Functions as team leader/senior-level Medical Reviewer.
Provides leadership/guidance/direction/training to staff.
Maintains working knowledge of unit functions and ability to interpret to new hires, department innerworkings and workflow.
Acts as resource for staff/external entities troubleshooting as well as resolving issues.
Keeps manager informed of any problems/issues that need resolving.
Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
Participates in departmental quality reviews.
Follows process to ensure quality plan is adhered to and communicated to all parties.
Gives/receives feedback regarding medical review decision making and technical claims processing issues.
Ensures that quality work instructions/forms/documents are developed/revised as needed.
Provides quality service and communicates effectively with external/internal customers in response to inquiries.
Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
Participates in compliance initiatives and other-directed activities.
Participates/oversees special projects as requested by management.