Logistics: Palmetto GBA - one of BlueCross BlueShield of South Carolina’s subsidiary companies.

Location: This is a work from home ( W@H) opportunity for qualified candidates.

Sponsorship This position is not eligible for sponsorship now or in the future.

What you will do:

• Manages day-to-day activities for assigned staff. Identifies training needs and verifies accuracy and timeliness of workflow functions.

• Supervises staff to include approval of time, leave, performance reviews, etc. Selects/trains/motivates staff in providing excellent customer service with customers, marketing, management/others.

• Performs quality control functions for work performed. Develops work plans to improve quality performance. Prepares/reviews/maintains weekly/monthly reports.

• Develops/maintains/updates procedures/documentation for conducting audits. Develops/communicates department standards and expectations of staff. Coordinates special projects, system testing enhancements, etc.

To Qualify for This Position, You'll Need The Following:

Required Education:

• Associate's in a job-related field.

• Degree Equivalency: Graduate of Accredited School of Nursing.

Required Work Experience:

• 5 years clinical or 5 years utilization review/medical review experience (3 of the 5 must be clinical).

• 1 year team lead/leadership role or equivalent military experience in grade E4 or above (may be concurrent with the 5 years).

Required Skills and Abilities:

• Working knowledge of word processing, spreadsheet, and database software.

• Ability to work independently, prioritize effectively, and make sound decisions.

• Working knowledge of managed care and/or various forms of health care delivery systems; strong clinical experience to include home health, rehabilitation, and/or broad medical surgical experience. Knowledge of specific criteria/protocol sets and the use of the same.

• Good judgment skills.

• Demonstrated customer service, organizational, and presentation skills.

• Demonstrated proficiency in spelling, punctuation, and grammar skills. Ability to persuade, negotiate, or influence others. Analytical or critical thinking skills.

• Ability to handle confidential or sensitive information with discretion.

• Ability to lead, motivate, and assess performance of others.

• Required Software and Tools: Microsoft Office.

Required Licenses and Certificates:

• 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).

We Prefer You Have the Following:

• Preferred Education: Bachelor's degree in nursing (BSN) or Masters degree in nursing (MSN) or MSN in Nursing Education. **However, additional clinical experience will be considered, in lieu of the preferred education.

• Preferred Work Experience: Three years-utilization/medical review, quality assurance, OR home health, plus 5 years clinical experience. Experience with PA & RCD Programs, FISS, MCS.

• Preferred Skills and Abilities: Knowledge of Spreadsheet and database software. Knowledge of Medicare and/or regulations/policies/instructions/provisions, home health, and/or system/processing procedures for medical review. Excellent presentation skills.

• Preferred Software and Other Tools: Working knowledge of Microsoft Excel, Access, OR other spreadsheet database software.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards. You will be eligible to participate in our benefits program 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.