Lead Case Manager in Enhanced Care Management addressing social determinants of health. Support members through comprehensive care coordination and active community engagement in San Benito County.
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Hybrid Manager, Medical Review – Medicare, Appeals, Utilization Review, Part A, HHH
Posted 4 days ago
About the role
- Manager overseeing medical review processes for Medicare claims at BlueCross BlueShield of South Carolina. Ensuring compliance with standards and laws while driving continuous improvement in claim processing.
Responsibilities
- Oversees 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
- Manages and oversees the accurate processing of claims deferred for medical necessity review
- Drives continuous improvement by identifying and implementing process enhancements
- Supports team accountability and maintains high-quality performance standards
- Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required
Requirements
- Bachelor's degree in a job-related field
- 5 years clinical and utilization review including 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above
- Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills
- Good judgment skills
- Proficient spelling, grammar, punctuation, and basic business math
- Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion
- Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
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
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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