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Summary
 Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for commercial stop loss programs.This role 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. Works collaboratively with owned division and program partners 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.
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:

Lead, organize, and develop staff in administration of the Medical Review and Prior Authorization programs for commercial stop loss programs.This role 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. Works collaboratively with owned division and program partners 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.

Logistics:

https://www.companionlife.com/ - one of BlueCross BlueShield of South Carolina's subsidiary companies.

Location:

This is a remote position. Typical work hours are from 8:30am - 5pm, Monday through Friday.

What You'll Do:

• 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 effectives 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.

To Qualify For This Position, You'll Need The Following:

• Required Education: Bachelor's in a job related field
• Required Work Experience: 10 years healthcare program management, utilization/case management, or medical review management or equivalent military experience in grade E4 or above.
• Required Skills and Abilities: 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.
• Required Software and Other Tools: Microsoft Office. Knowledge of medical systems software.
• Required Licenses and Certificates: If RN, active RN licensure in state hired.

We Prefer That You Have The Following:

• Preferred Work Experience: 8 years of commercial/ self-funded program management, utilization/case management, or medical review management or equivalent military experience grade E4 or above. May be concurrent. 5 years of Stop Loss experience.
• Preferred Skills and Abilities: In-depth knowledge of the Medicare Medical Review and Prior Authorization program. Knowledge of pricing large stop loss claims in coordination with other clinical staff and underwriting teams. Excellent decision making and problem solving. Demonstrated knowledge of developing, monitoring, and overseeing budgets. Working and managing cost containment vendors, and managing and negotiating associated contracts. Developing of medical policies and guidelines for general underwriter organizations. Extensive knowledge of cell and gene therapy & impact to future health care costs and quality.
• Preferred Licenses and Certificates: American Society for Quality Certification.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next:

After 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 our recruiter to verify resume specifics and salary requirements.

Pay Range Transparency:

Range Minimum: $122,441.00

Range Midpoint: $180,746.00

Range Maximum:$239,051.00

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

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 individuals with disabilitiesand protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.comor call 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.

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

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