Medical Review Manager

We are currently hiring for a Medical Review Manager to join BlueCross BlueShield of South Carolina. In this role as a Medical Review Manager, you will oversee the accurate processing of claims that have been deferred for medical necessity review. Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations. Identifies and implements process improvement opportunities. This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Logistics: This position is full time (40 hours/week) Monday-Friday from 8:00am-4:00pm and can be on-site or remote depending on the applicant’s location.

Manages the medical review process. Maintains a well-trained staff. Develops/implements medical review strategy with the ultimate goal of reducing the error rate. Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations. Identifies missed standards and implements corrective actions. Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action. Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner. Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required to build and maintain positive customer relationships.as assigned by management.