Medical Review Supervisor

About the Company

BlueCross BlueShield of South Carolina has been a cornerstone of the national healthcare landscape for over seven decades, with deep roots in the South Carolina community. As the largest insurance company in the state, we are also one of the nation’s leading administrators of government contracts, operate one of the Southeast’s most sophisticated data processing centers, and maintain a diverse family of subsidiary companies. Our commitment to outstanding service drives everything we do.

About the Role

This position is responsible for supervising and maintaining the daily functions of Utilization Review, Review Nurses, Case Management, and/or Medical Review staff and specialty programs. You will ensure appropriate levels of healthcare services are provided while managing day-to-day activities, staff performance, and quality control.

This is a work-from-home (W@H) opportunity with Palmetto GBA, a subsidiary of BlueCross BlueShield of South Carolina. This position is not eligible for sponsorship now or in the future.

Responsibilities

• Manage day-to-day activities for assigned staff, including approval of time, leave, and performance reviews.
• Identify training needs and verify accuracy and timeliness of workflow functions.
• Supervise, select, train, and motivate staff to provide excellent customer service to customers, marketing, management, and others.
• Perform quality control functions for work performed and develop work plans to improve quality performance.
• Prepare, review, and maintain weekly and monthly reports.
• Develop, maintain, and update procedures and documentation for conducting audits.
• Develop and communicate department standards and expectations of staff.
• Coordinate special projects, system testing enhancements, and other initiatives.

Requirements

• Associate’s degree in a job-related field or graduation from an accredited School of Nursing.
• 5 years of clinical experience or 5 years of utilization review/medical review experience (3 of the 5 years must be clinical).
• 1 year of team lead/leadership experience or equivalent military experience in grade E4 or above (may be concurrent with the 5 years of experience).
• Active, unrestricted RN licensure from the United States and in the state of hire, or an active, compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

Skills and Abilities

• Working knowledge of word processing, spreadsheet, and database software (e.g., Microsoft Office).
• Ability to work independently, prioritize effectively, and make sound decisions.
• Working knowledge of managed care and/or various forms of healthcare delivery systems; strong clinical experience, including home health, rehabilitation, and/or broad medical-surgical experience.
• Knowledge of specific criteria/protocol sets and their application.
• Strong judgment, customer service, organizational, and presentation skills.
• Proficiency in spelling, punctuation, and grammar.
• Ability to persuade, negotiate, or influence others.
• Analytical and critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Ability to lead, motivate, and assess the performance of others.

Preferred Qualifications

• Bachelor’s degree in nursing (BSN), Master’s degree in nursing (MSN), or MSN in Nursing Education. Additional clinical experience may be considered in lieu of preferred education.
• Three years of utilization/medical review, quality assurance, or home health experience, plus 5 years of clinical experience.
• Experience with PA & RCD Programs, FISS, or MCS.
• Knowledge of Medicare regulations, policies, or provisions, as well as home health and/or system/processing procedures for medical review.
• Working knowledge of Microsoft Excel, Access, or other spreadsheet/database software.
• Excellent presentation skills.

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 programs.
• National discounts to movies, theaters, zoos, theme parks, and more.

Benefits eligibility begins the first of the month following 28 days of employment.