Senior Medical Reviewer

Summary: Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided. Description: 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.

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.