Director Of Dme Medical Review

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 have been part of the national landscape. BlueCross BlueShield of South Carolina is one of the nation's leading administrators of government contracts and operates one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, including CGS Administrators, that allows us to build on a variety of business strengths. CGS Administrators provides a variety of services, under contracts with the Centers for Medicare and Medicaid Services (CMS) for beneficiaries, health care providers, and medical equipment suppliers in 33 states, supporting the needs of more than 20 million Medicare beneficiaries nationwide. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose: As the Director of the DME Medical Review Department, you will oversee the operations of a dynamic team of approximately 150 clinical and non-clinical professionals. With primary responsibility for the following:

• Operational Oversight: Ensuring smooth and efficient day-to-day operations within the department.
• Team Leadership: Guiding and mentoring a diverse team to achieve their full potential
• Performance Management: Setting and monitoring performance expectations to drive excellence
• Compliance Assurance: Upholding stringent compliance standards to meet regulatory and customer contractual requirements.
• Financial Stewardship: Strategically managing resources to achieve financial objectives and sustain departmental growth.

Logistics:

This position is full-time (40 hours/week, 8 hours/day) Monday Friday ONSITE at One Century Plaza (OCP), Nashville, TN.

What You'll Do:

• Oversees operations of assigned area.
• 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 area.

To Qualify for This Position, You'll Need:

• Required Education: Bachelor's degree - Business Administration, Healthcare Administration, Nursing, or other related field.
• Required Work 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:
• Ability to use standard office equipment.
• Knowledge of word processing, spreadsheet, and database software.
• Knowledge of medical management systems.
• 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 You to Have:

• Strong Microsoft Office Skills
• Process-oriented work style
• RN license STRONGLY PREFERRED
• Knowledge of Medicare contracting/Medicare policy/regulations/DME
• Excellent decision making and problem solving.
• Data-centric, ability to understand and make decisions based on data trends
• Demonstrated knowledge of developing, monitoring, and overseeing budgets.
• 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.

What Blue 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.

Our comprehensive benefits package includes:

• 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
• Wellness program and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more

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.

Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

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