Senior Medical Review Director – Stop Loss

🕒 April 25

🐊 Florida, North Carolina, +2 more states – Remote

🐊 Florida – Remote 🌲 North Carolina – Remote 🌴 South Carolina – Remote ☕ Washington – Remote

⏰ Full Time

🟠 Senior

👔 Director

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Insurance • Finance

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for government programs • Directs and oversees 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 the Center for Medicare and Medicaid Service (CMS) guidelines • Guides the Medical Review Team in the development and implementation of an efficient and effective Medical Review Strategy, including the integration of policy and education, that optimizes critical Medical Review cycle times • Serves 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 • Directs and oversees the development of the Medical Review and Prior Authorization Program strategy and error rate reduction plans based on the findings • Develop and implement the Medical Review Programs strategic plan with goals supportive of the corporate strategic plan • 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

🎯 Requirements

• 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 • If RN, active RN licensure in state hired.

🏖️ Benefits

• 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