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About the Role
This role serves as the primary point of contact for all activities related to the Administrative Law Judge (ALJ) program, including medical record review, policy analysis, preparing team members for hearings, writing position papers, and testifying on behalf of CGS and the Medicare Program.
Responsibilities
- Provides clinical expertise, research, and judgment to develop Local Coverage Determinations (LCDS) under the direction of medical director.
- Maintains LCDS once developed.
- Educates providers and internal customers on LCDS.
- Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance.
- Provides clinical input for internal requests.
- Serves as reviewer to determine inter-rater reliability.
Requirements
- Bachelor's in a job related field.
- Associate's degree in Nursing with an active RN license.
- 5 years clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.
- Knowledge of managed care or medical claims payment policy issues.
- Working knowledge of word processing and spreadsheet software.
- Excellent verbal and written communication skills.
- Excellent customer service, organizational, presentation, analytical or critical thinking skills.
- Ability to persuade, negotiate, or influence others.
- Ability to handle confidential or sensitive information with discretion.
- Sound clinical review judgement.
- Independent thinking and strong organizational skills.
- Microsoft Office.
- An active, unrestricted RN license 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).
- For Division 33, Certified Genetic Counselor will be considered in lieu of RN License.
- Ability to obtain a security clearance.
- Must be a U.S. Citizen.
Skills
- Managed care or medical claims payment policy issues
- Word processing software
- Spreadsheet software
- Verbal communication
- Written communication
- Customer service
- Organizational skills
- Presentation skills
- Analytical skills
- Critical thinking skills
- Persuasion
- Negotiation
- Influence
- Handling confidential information
- Clinical review judgement
- Independent thinking
- Microsoft Office
- Database software
- Government/healthcare programs and contracts laws, regulations
- Government/healthcare programs and regulations, coding, and approval practices
- Corporate administrative/medical policy
- Guidelines, benefits, and coverage for all lines of business
- Microsoft Access
- DB2
- Easytrieve
Location
- Nashville, TN
Work Type
- Full-time
- Hybrid
- Remote
Experience Level
- 5 years clinical experience
- 7 years clinical experience
Education Level
- Bachelor's in a job related field
- Associate's degree in Nursing with an active RN license
- Bachelor's degree- Nursing
Salary/Compensations
- $55,251.00 - $105,492.00
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
- National discounts to movies, theaters, zoos, theme parks and more
- Continuing education funds for additional certifications and certification renewal.
About the Company
- CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years.
- This is an opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.
Equal Opportunity
- 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.
- As a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and 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.
- We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision.
- We are an Equal Opportunity Employer.