Associate Medical Director DME

Internal Reference Number

R1048061

Why should you join the Blue Cross Blue Shield 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, one of the nation's leading administrators of government contracts, and operate one of the most sophisticated data processing centers in the Southeast. A diverse family of subsidiary companies lets us build on various business strengths, allowing us to deliver outstanding service to our customers.

If you share our philosophy, consider joining our team!

As a member of the Pricing, Data Analysis and Coding (PDAC) team, the Associate Medical Director DME provides administrative oversight to the medical staff, analyzes medical review utilization data, researches new medical devices and technology, and acts as a resource to CMS, DMEPOS stakeholders, and internal staff on issues concerning medical device coding and DMEPOS policies. In this role you also oversee coding integrity efforts and write and revise coding advisory articles with regard to Medicare policy and procedure.

Palmetto GBA - one of Blue Cross Blue Shield's South Carolina subsidiary companies.

This position is full‑time (40 hours/week) Monday‑Friday, with an 8‑hour shift during normal business hours 8:00 AM‑5:00 PM. Occasional overtime may be required. The role is located at our Government Programs Building at 17 Technology Circle, Columbia, SC or can be remote in the United States. Required travel is part of the position.

This position requires the ability to obtain a security clearance and requires applicants to be a U.S. citizen.

• Support operations through case review on medical and regulatory matters.
• Develop claim adjudication criteria for situations requiring medical judgment.
• Provide input on issues and operational policies, processes, and procedures.
• Educate staff and the medical community on various aspects of medical policy and program administration.
• Develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.
• Develop external relationships with the medical community and serve as liaison between these entities and contractors.
• Review physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
• Conduct research into new or controversial medical procedures and technology.

Education: Doctoral degree in Medicine (MD) with a current active license to practice medicine.

Experience:

• Five years of post‑graduate experience in direct patient care.

Skills and Abilities:

• 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.

Software: Microsoft Office.

License and Certificate: Active state medical license and current board certification in a recognized specialty.

• Certified Professional Coding preferred.
• Knowledge of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).
• Medicare A/B MAC or DME MAC.
• Experience working in rehabilitation.
• Three or more years in the healthcare insurance industry, a utilization review or other administrative experience involving development of coverage and coding policies and guidelines.
• Experience with Medicare program contracts preferred.

We offer a comprehensive benefits package, with eligibility beginning the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage.
• 401(k) 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,…