Consultant, Sr Provider Education

Internal Reference Number: R1048604

Provides education to medical providers as warranted.

Logistics

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

Government Clearance

This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Location

This a full-time remote position. You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.

-5:00 p.m. Monday - Friday. It may be necessary, given the business need, to work occasional overtime.

What You'll Do:

• Communicates/educates providers on issues such as Medicare coverage, utilization statistics, documentation and medical review by use of written advisories, reports, letters, and telephone contacts.
• Documents all provider contacts/communications in provider tracking system.
• Conducts formal conference calls and/or in-person educational visits with providers that are consistently over utilizing services, on progressive corrective action, or have unacceptable denial rates and/or error rates under the medical review program.
• Conducts coverage and documentation workshops for provider staff (Medicare providers and physicians' staff).
• Researches, composes, and coordinates the preparation of all regulatory based provider education materials.
• Performs analysis of effective reports to determine actions to be taken regarding medical reviewed its/audits.
• Determines what providers are over-utilizing services and what services are being over-utilized.
• Works with medical review department and provides input regarding actions taken in response to provider billing practices.
• Targets providers where greatest abuse of Medicare program has occurred.
• Participates in the medical review process and inter reviewer reliability (IRR) studies.
• Assists in training of medical review associates regarding coverage and medical review process.

To Qualify for This Position, You'll Need the Following:

• Required
  
  Education:
  
  If LPN, graduate of accredited School of Licensed Practical Nursing; if LVN, graduate of accredited School of Licensed Vocational Nursing; if RN, graduate of approved School of Nursing.
• Required Experience: If LPN or LVN, 7 years of clinical experience or equivalent combination of clinical and educator experience. If RN, 5 years of clinical experience or equivalent combination of clinical and educator experience.
• Required Software and tools: Microsoft Office.
• Required
  
  Skills and Abilities:
  
  Knowledge of medical terminology and disease processes. Demonstrated proficiency in word processing and spreadsheet software. Good judgment skills. Effective customer service, organizational, and presentation skills. Demonstrated proficiency in spelling, punctuation, and grammar. Analytical or critical thinking skills. Basic business math proficiency. Knowledge of mathematical or statistical concepts. Ability to persuade, negotiate, or influence.
• Required Licenses and Certificates: Active LPN or LVN licensure in state hired, OR active compact multistate LPN license as defined by the Nurse Licensure Compact (NLC), OR active RN licensure in state hired OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC) others. Ability to handle confidential or sensitive information with discretion.

We Prefer That You Have the Following:

• Preferred
  
  Work Experience:
  
  3 years of provider relations and Medicare experience.
• Preferred
  
  Skills and Abilities:
  
  Knowledge of claims processing software. In-depth knowledge of Medicare program, guidelines, regulations governing coverage.
• Preferred Software and Other Tools: Working knowledge of Microsoft Access or other database software.

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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

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 the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What 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.

Equal Employment Opportunity Statement

Blue Cross Blue Shield 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,…