Senior Medical Review Director

🕒 Abril 13

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BlueCross BlueShield of South Carolina

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1946

⚕️ Seguro de Saúde

💸 Finanças

Healthcare Insurance • Insurance • Finance

Há mais de seis décadas, a BlueCross BlueShield of South Carolina faz parte do panorama nacional. Nossas raízes estão firmemente enraizadas no estado. Somos a maior companhia de seguros na Carolina do Sul. Somos também a única com uma classificação A+ Superior da A.M. Best. Somos um dos principais administradores de contratos governamentais do país. Operamos um dos centros de processamento de dados mais sofisticados do Sudeste e temos uma diversificada família de empresas subsidiárias.

Descrição

• Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for government programs • Direct and oversee the Medical Review and Prior Authorization programs ensuring performance expectations, compliance standards, workload issues, quality control, training and maintaining effective staffing levels and budgetary limits are maintained per CMS guidelines • Guide the Medical Review Team in the development and implementation of an efficient and effective Medical Review Strategy • Serve as the Medical Review and Prior Authorization liaison between internal and external stakeholders • Ensure system/operational compliance with CMS directives • Establish, guide and analyze the effectiveness of Medical Review and Prior Authorization operations against benchmarks that are developed as measures of success • Analyze performance trends and develop new/modified work processes to improve overall operations quality/timeliness/customer satisfaction/financial outcomes • Direct/develop/evaluate/motivate subordinates to achieve and maintain production and quality standards ensuring area review decisions are accurate and all associates are well informed and trained on contract process work instructions • Direct and oversee the development of the Medical Review and Prior Authorization Program strategy and error rate reduction plans based on findings • Manage budget to ensure cost-effectiveness and performance quality • Serve as the liaison and maintain proactive working relationship with CMS and other Medicare program leadership as needed by contract • Investigate and resolve action items assigned by executive management • Resolve priority level problems from providers, beneficiaries, and CMS

🎯 Requisitos

• Bachelor's in a job related field • 10 years healthcare program management, utilization/case management, or medical review management or equivalent military experience in grade E4 or above • Excellent verbal and written communication skills • Excellent organizational, customer service, analytical or critical thinking skills • Excellent presentation skills • Good judgment skills • Ability to persuade, negotiate, or influence others • Ability to evaluate existing processes and develop ways to streamline procedures • Strong organizational, analytical, communication, and decision-making skills • Knowledge of budget preparation and management • Ability to handle difficult situations • Ability to easily adapt to change • Microsoft Office proficiency • Knowledge of medical systems software • If RN, active RN licensure in state hired

🏖️ Benefícios

• Subsidized health plans • Dental and vision coverage • 401k retirement savings plan with company match • Life Insurance • Paid Time Off (PTO) • On-site cafeterias and fitness centers in major locations • Education Assistance • Service Recognition • National discounts to movies, theaters, zoos, theme parks and more