Summary
We are currently hiring for a Corporate Appeals Manager to join BlueCross BlueShield of South Carolina. In this role as a Corporate Appeals Manager, you will oversee appeals process/case review process and staff ensuring all documentation, timeliness, and quality standards are met. Ensures cost effective plans provide a positive impact on the quality of life and clinical outcomes of individuals. Ensures compliance with state and federal requirements. Identifies and implements process improvement opportunities. Presents programs and program results to internal/external customers.
Location
This position is full-time (40 hours/week) Monday-Friday, from 8:30am – 5:00pm EST and will be hybrid in Columbia, SC. The candidate will be required to report on-site up to 3-days a week during the 3-month training period.
What You'll Do
- Oversees appeals/case review clinical and support staff and operations and identifies training needs of staff. Supervises the development and administration of appeals/case review services ensuring regulatory, contract, national accreditation and program requirements are met (including NCQA, HEDIS, URAC, DOL, DOI, and HIPAA).
- Identifies, develops, and implements quality initiatives, compliance oversight, corrective actions, and provides reporting as required for quality improvement.
- Develops and implements tracking, trending, and cost containment initiatives.
- Provides clinical input/direction for advanced and complicated case review.
- Interfaces with internal and external customers. Develops and presents appeals/case review educational programs.
- Provides oversight of employee recruitment, hiring, training, and retention strategies.
To Qualify for This Position, You'll Need the Following
- Required Education: Bachelor's in a job-related field
- Degree Equivalency: Graduate of Accredited School of Nursing. (Equivalency not applicable for the Celerian Group. Bachelor's degree required.)
- Required Experience: 5 years' clinical experience to include direct patient care, appeals, or utilization review. 2 years supervisory/team lead experience (concurrent) or equivalent military experience in grade E4 or above.
- Required Skills and Abilities: Knowledge/understanding of utilization review guidelines, managed care delivery systems.
- Working knowledge of word processing, spreadsheet, presentation software.
- Ability to work independently, prioritize effectively, make sound decisions.
- Effective customer service and organizational skills.
- Demonstrated presentation skills in order to work effectively with both internal and external customers.
- Demonstrated proficiency in spelling, punctuation, and grammar skills.
- Analytical or critical thinking skills.
- Ability to persuade, negotiate, or influence others.
- Ability to handle confidential or sensitive information with discretion.
- Ability to direct, motivate, and assess performance of others.
- Required Software and Tools: Microsoft Office.
- Required License/Certificate: Active, unrestricted RN licensure from the United States and in the state of hire, OR, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, active, unrestricted licensure as Social Worker or Counselor from the United States and in the state of hire (for Div. 75 only).
What We Prefer You to Have
- Strong Leadership Skills: Ability to lead and motivate a team, fostering a positive and productive work environment.
- Excellent Communication: Clear and effective communication skills, both written and verbal, to interact with stakeholders at all levels.
- Analytical Thinking: Strong analytical skills to assess complex cases and make informed decisions.
- Attention to Detail: Meticulous attention to detail to ensure accuracy and compliance in all aspects of the appeals process.
- Problem-Solving Abilities: Creative and proactive approach to identifying and resolving issues.
- Driven: A strong inner motivation to achieve goals, overcome challenges, and continuously improve.