Internal Reference Number: R1046999 Summary Why should you join the BlueCross BlueShield of South Carolina family of companies?

Other companies come and go, but for more than seven decades we've been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose:

Directs and oversees operations in the medical review, clinical pricing, and re-determination areas ensuring performance expectations, compliance standards, and budgetary limits are maintained. Supervises and motivates area employees.Description Logistics: PGBA - one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located at 8733 Highway 17 Bypass, Myrtle Beach, SC 29575. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

What You'll Do: Oversees operations of assigned areas. Coordinates tactical team activities. Ensures area review decisions are accurate and all associates are well informed and trained on contract process work instructions.

Reviews and analyzes data and creates departmental strategy and error rate reduction plans based on the findings.

Provides guidance on the analysis, identification, and corrective actions of services and/or providers with suspected abuse of the program.

Works closely with the Provider Service Center and other internal departments, providing necessary assistance and resources, to ensure consistency and achieve the integrated goals of reducing the claims payment error rate and procurement of additional contracts.

Develops and monitors budget for all assigned areas.

To Qualify For This Position, You'll Need The Following: Required Education: Bachelor's in a job related field.

Required Experience: 5 years healthcare program management, utilization/case management, or medical review management to include 3 years of supervisory/management experience or equivalent military experience in grade E4 or above.

Required Software and tools: Microsoft Office. Knowledge of medical systems software.

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.

We Prefer That You Have The Following: 8 years-healthcare program management, utilization/case management, or medical review management to include 3 years of supervisory/management experience or equivalent military experience grade E4 or above.

Ability to negotiate and seek consensus with key stakeholders.

In-depth knowledge of the Medicare program.

Excellent decision making and problem solving.

Demonstrated knowledge of developing, monitoring, and overseeing budgets.

Preferred Licenses and Certificates: Active RN licensure in state hired. American Society for Quality Certification. Work Environment: Typical office environment frequent. Travel between office buildings. Some out of town travel. 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. 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. Some states have required notifications. Here's more information.