Medicare Medical Director - Palmetto GBA

SummaryAs member of the senior management team, provides administrative oversight to the medical staff, analyzes medical review utilization data, researches new medical procedures or technology, and acts as a resource to providers and internal staff on issues concerning medical policies. May also write and revise medical policies.DescriptionWhy should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we''ve been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!This open position is within one of our subsidiary companies called Palmetto GBA. Palmetto GBA is a leading provider of high-volume claims and transaction processing, contact center operations and technology services to the federal government. Our core business is to provide support to the Centers for Medicare & Medicaid Services (CMS), Medicare beneficiaries and Medicare providersWhat You''ll Do:Supports operations in the form of case review on both medical and regulatory matters. Develops claim adjudication criteria for situations requiring medical judgment. Provides input on issues and operational policies, processes, and procedures.Educates staff and medical community on various aspects of medical policy and program administration.May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies. Develops external relationships with the medical community and serves as liaison between these entities and the contractors.Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.Conducts research into new or controversial medical procedures and technology.To Qualify for This Position, You''ll Need:Doctorate degree Medical Doctor (MD) or or Osteopathic Doctor (DO) with current active license to practice medicine.Active state medical license and current board certification in a recognized specialty.Five years post graduate experience in direct patient care. (Experience may include paid training.)Excellent verbal and written communication skills.Excellent customer service, organizational, and presentation skills. Proficiency in spelling, punctuation, and grammar.Ability to persuade, negotiate, or influence others.Ability to work as a team member as well as a leader.Knowledge of medical and utilization review techniques.Microsoft Office.We prefer that you have:Medicare experience including exposure to National Coverage Determinations (NCD) and Local Coverage Determinations (LCD).Experience interpreting medical evidence, research experience and/or publishing peer reviewed articles.Knowledge of or experience with the Medicare appeals process.Work Environment:Typical office environment frequent. Travel between office buildings. Some out of town travel.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 access and opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.Our comprehensive benefits package includes:401(k) retirement savings plan with company matchFantastic health plans and free vision coverageLife insurancePaid annual leave - the longer you work here, the more you earnNine paid holidaysOn-site cafeterias and fitness centers in major locationsWellness programs and a healthy lifestyle premium discountTuition assistanceService recognitionWhat 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. Management will be conducting interviews with those candidates who qualify with prioritization given to those candidates who demonstrate the preferred qualifications.We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Equal Employment Opportunity StatementBlueCross 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. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and 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 physical and mental disabilities.If you need special assistance or an accommodation while seeking employment, please e-mail [Click Here to Email Your Resumé] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

Created: 2025-11-15