Palmetto GBA hiring Senior Medical Reviewer (Medicare Part A) - Palmetto GBA in Columbia, South Carolina, United States | LinkedIn (2024)

SummaryActs 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.

DescriptionLogistics:

• Potential to work from home based on candidate location.
• To work from home, you must have high-speed (non-satellite) internet service and a private home office.
• Will require travel to Columbia SC office based on needs of the department.

What You Will Do

• 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 interworking 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.

To Qualify For This Position, You Will Need

• Required License and Certificate: 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.
• Required Education: Associate Degree - Nursing, OR Graduate of accredited School of Nursing.
• Required Work Experience: Four years clinical nursing experience, OR two years clinical nursing experience and two years medical review/utilization review, OR combination of health plan, clinical, and business experience totaling four years.
• Required Skills and Abilities: Demonstrated skills in training material development and presentations to groups via web and classroom. Minimum of intermediate level computer skills to support the development and presentation of training materials. Ability to critically think and use clinical judgment when rendering MR decisions. Working knowledge of managed care and various forms of health care delivery systems. Strong clinical experience to include DME, 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. 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.
• Required Software and Tools: Microsoft Office.

What We Prefer You Have

• Current Home Health and Hospice Medical Review experience.
• Current working knowledge/ experience of the Senior Medical Reviewer position to include roles and responsibilities.
• Cross trained in MCCM and New Mexico Claims.
• Previous leadership experience.
• Ability to present information to outside agencies such as OIG, DOJ and collaboratively within Palmetto GBA.
• Experience with working with internal as well as external Auditors to include CMS when on site.
• Experience with Software and systems
• Ability to train and share educational opportunities to staff as well as collaboratively with other Lines of Business.

What We Can Do For You

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.

What To Expect NextAfter submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualified candidates.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.