Senior Medical Review Director - Stop Loss Focus

Job Summary Lead, organize, and develop staff in the administration of the Medical Review and Prior Authorization programs for commercial stop‑loss programs. Direct and oversee program performance, compliance, quality control, training, staffing, and budgetary limits. Work collaboratively with internal and external stakeholders and serve as liaison between program partners. Location Remote position. Typical work hours: 8:30am – 5:00pm, Monday‑Friday. Key Responsibilities Ensure system and operational compliance with CMS directives. Establish, guide, and analyze the effectiveness of Medical Review and Prior Authorization operations against benchmarks. Analyze performance trends and develop new or modified work processes to improve quality, timeliness, customer satisfaction, and financial outcomes. Direct, develop, evaluate, and motivate subordinates to achieve production and quality standards, ensuring accurate review decisions and comprehensive training. Develop and oversee error‑rate reduction plans and the overall Medical Review strategy aligned with corporate goals. Manage the program budget to maintain cost effectiveness and quality performance. Serve as the liaison with CMS and Medicare program leadership, maintaining a proactive working relationship. Investigate and resolve action items assigned by executive management. Resolve priority‑level problems reported by providers, beneficiaries, and CMS. Required Qualifications Bachelor’s degree in a related field. 10+ years of healthcare program management, utilization/case management, or medical review management experience (or equivalent military experience, grade E4 or above). Excellent verbal and written communication skills. Strong organizational, customer‑service, analytical, and critical‑thinking abilities. Effective presentation, judgment, persuasion, negotiation, and influence skills. Ability to evaluate and streamline existing processes. Knowledge of budget preparation and management. Proficiency in Microsoft Office and medical systems software. Active RN licensure in the state of hire (if RN). Preferred Qualifications 8+ years of commercial / self‑funded program management, utilization/case management, or medical review management experience (or equivalent military experience, grade E4 or above). 5+ years of stop‑loss experience. In‑depth knowledge of the Medicare Medical Review and Prior Authorization program. Experience with pricing large stop‑loss claims in coordination with clinical staff and underwriting teams. Excellent decision‑making and problem‑solving skills. Demonstrated ability to develop, monitor, and oversee budgets. Experience managing cost‑containment vendors and negotiating associated contracts. Experience developing medical policies and guidelines for underwriter organizations. Knowledge of cell and gene therapy and its impact on future healthcare costs and quality. American Society for Quality certification (preferred). Benefits Subsidized health, dental, and vision coverage. 401(k) retirement savings plan with company match. Life insurance. Paid Time Off (PTO). On‑site cafeterias and fitness centers at major locations. Education assistance. Service recognition. National discounts to movies, theaters, zoos, theme parks, and more. Pay Range Transparency Minimum: $122,441.00 | Midpoint: $180,746.00 | Maximum: $239,051.00 Equal Employment Opportunity Statement BlueCross BlueShield of South Carolina and its subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, 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. We are committed to providing reasonable accommodations to individuals with disabilities, pregnant individuals, and those with pregnancy‑related conditions or sincerely held religious beliefs, unless it imposes an undue hardship on the company. Contact Information For assistance or a reasonable accommodation request, email View email address on click.appcast.io or call View phone number on click.appcast.io. #J-18808-Ljbffr 001 BlueCross and BlueShield of South Carolina