Get Hired Faster With COMPANY_NAME!
Don't you ever think you landed here by any accident, You are here because you are searching for something bigger. You know what?
- A better Job
- A better Future
- A better Knowledge
- A better Paycheck
- A greater Path to walk on.
And COMPANY_NAME is here to give you exactly what you've been missing for so long. The reality is that most job seekers chase job postings, but successful job seekers attract job offers by chasing the accurate information. Therefore, that's the shift COMPANY_NAME is going to help you make. Here are the top 10 ideas to up-skill yourself, so lean in to begin:
1: COMPANY_NAME Smart Tools and Direct Employer Connections Help Speed Up Your Hiring Process
COMPANY_NAME is a career-changing advantage that most seekers never get access to. Imagine...
- Instead of applying for job after job and still not getting any callbacks, you suddenly bump into a tool that can do the heavy lifting for you.
- Instead of wondering, "What do employers actually want?", you are getting insights straight from the employer's desk.
- Instead of hoping your resume gets noticed, it’s kept on the table of decision-makers who are hiring right now.
That's the difference COMPANY_NAME makes. Our tools will let you reach employers directly, which automatically speeds up your hiring process.
2: With Better Matches, Real-time Job Alerts, and Direct Employer Responses, COMPANY_NAME Helps Many Candidates Secure Interviews and Job Offers Within 15 to 30 Days!
How does COMPANY_NAME make this possible?
On COMPANY_NAME, you get notified for roles aligned with your profile right from the start. When an employer posts a role that matches your qualifications and skills, you’ll know first. When you apply early, your chances of getting noticed and shortlisted increase by 20%.
COMPANY_NAME also offers direct employer responses—no more waiting for weeks. Here you engage with hiring managers who are actively looking for candidates.
When all these features combine in one place, you move from your first match to your first interview within days. And ultimately, from application to offer—all within 15 to 30 days!
3: The Type of Resume You Need to Get Priority Placement
With COMPANY_NAME, you don’t just need a resume—you need a strategy. A system that pushes your name to the right tables. We’ll show you exactly how the most successful candidates take initiative and get noticed.
4: Browse Full-Time, Part-Time, and Freelancing Roles With COMPANY_NAME
The job market isn’t one-size-fits-all—and your career shouldn’t be either. COMPANY_NAME gives you access to a wide range of opportunities including full-time, part-time, and freelancing roles all in one place.
5: COMPANY_NAME Helps You Grow Your Career
COMPANY_NAME provides insights, tools, and role-matching that help you find the right direction, the right skills, and the opportunities aligned with your ambition.
6: The Easiest Way To Find A Job
COMPANY_NAME cuts the noise, the endless scrolling, and the confusion. With accurate matches, direct employer connection, and real-time updates, you get a clear and simple path from application to interview.
7: Find Roles That Offer Growth, Culture & Benefits
COMPANY_NAME helps you find roles where you grow, feel supported, and thrive—not just survive. With us, you discover opportunities that elevate your professional life.
8: Get Support With Resume, Interviews & Career Planning
COMPANY_NAME provides expert guidance on resumes, interviews, and planning so employers instantly recognize your strengths and value.
9: Your Future Starts Today
COMPANY_NAME gives you everything you need—tools, guidance, and opportunities—to step forward confidently and begin a new chapter where your potential is seen and supported.
10: Get Hired Within 15 to 30 Days With COMPANY_NAME
COMPANY_NAME follows a smart, strategic, and proven approach that gets your profile noticed faster and moves you toward interviews and offers within 15 to 30 days.
RN Senior Medical Reviewer – ALJ Clinician *(Read position purpose), TN Anywhere
R1048201
Summary
Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas by providing assistance and support to unit supervisor/manager by giving direction/guidance/training to staff. Ensures appropriate levels of healthcare services are provided.Description
Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: This role requires a strong understanding of medical records review and the medical appeals process, with a particular focus on Administrative Law Judge (ALJ) decisions. Responsibilities include conducting comprehensive reviews of medical documentation and applying advanced knowledge of Medicare Local Coverage Determinations (LCDs), regulatory requirements, and applicable CMS guidelines and related policies to ensure accuracy, compliance and consistency in all determinations. Key responsibilities include analyzing second-level denial determinations, identifying deficiencies or rationale cited by reviewers, and compiling detailed summaries that accurately reflect the medical and procedural basis of each decision. The role also involves synthesizing complex clinical information and correlating it with ALJ rationale to support appeals strategy, identify trends, and ensure consistency with regulatory standards. The position requires the ability to interpret medical records, denial letters, and ALJ decisions holistically, ensuring that all relevant clinical facts and policy references are clearly documented. Strong attention to detail, critical thinking skills, and the ability to translate complex medical and legal findings into clear, actionable insights are essential. This work directly supports informed decision-making, compliance efforts, and successful appeal outcomes. Logistics:- CGS (cgsadmin.com) - one of BlueCross BlueShield's South Carolina subsidiary companies.
- This position is full time (40 hours/week) Monday through Friday. This is a W@H opportunity and can be located anywhere within the U.S. To work from home, you must have high-speed, non-satellite internet and a private home office space.
- Functions as team leader/senior-level Medical Reviewer. Provides leadership/guidance/direction/training to staff. Maintains working knowledge of unit functions and ability to interpret to new hires, department innerworkings and workflow. Acts as resource for staff/external entities troubleshooting as well as resolving issues. Keeps manager informed of any problems/issues that need resolving.
- Assists management with monitoring workflow and workloads (including reassignment of work to meet timelines, redirecting work intake source to balance workloads), reporting, and addressing aging issues.
- Participates in departmental quality reviews. Follows process to ensure quality plan is adhered to and communicated to all parties. Gives/receives feedback regarding medical review decision making and technical claims processing issues. Ensures that quality work instructions/forms/documents are developed/revised as needed.
- Provides quality service and communicates effectively with external/internal customers in response to inquiries. Obtains information from internal departments, providers, government, and/or private agencies, etc. to resolve discrepancies/problems.
- Participates in compliance initiatives and other-directed activities. Participates/oversees special projects as requested by management.
- Required License and Certificate: If RN, 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/certification from the United States and in the state of hire in specialty area as required by hiring division/area.
- Required Education: Associate Degree - Nursing, OR Graduate of Accredited School of Nursing.
- Required Work Experience: Four years clinical, OR Two years clinical and two years medical review/utilization review, OR, combination of health plan, clinical, and business experience totaling 4 years.
- Required Skills: Working knowledge of managed care and various forms of healthcare 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. Working knowledge of word processing and spreadsheet software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar skills. Demonstrated oral and written communication 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/direct/motivate others.
- Required Software: Microsoft Office.
- Bachelors degree in nursing or Graduate of Accredited School of Nursing.
- Ability to conduct second-level medical reviews of appeals and the ability to prepare comprehensive ALJ (Administrative Law Judge) position papers for hearings.
- Advanced knowledge of Medicare Local Coverage Determinations (LCDs), and related policies to ensure compliance and accuracy in all determinations.
- Strong analytical, writing, and communication skills are essential, along with the ability to work independently and manage multiple priorities under strict deadlines.
- Two years clinical and two years medical review/utilization review.
- Previous DME Medical Review experience.
- Proficient in Excel.
- Team player and Self-starter.
- 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
