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Summary Provides education to medical providers as warranted.
Description
Logistics: Palmetto GBA– one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This a full-time remote position for South Carolina, North Carolina, Georgia and Alabama candidates. You will work an 8-hour shift scheduled during our normal business hours of 8:30 a.m. – 5 p.m.
Sponsorship : This position is not eligible for sponsorship now or in the future.
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 Work 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 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 others. Ability to handle confidential or sensitive information with discretion.
Required Software and Tools: Microsoft Office.
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).
We Prefer That You Have the Following:
Preferred Work Experience: 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 Excel 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.
25% 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.
20% 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).
20% Researches, composes, and coordinates the preparation of all regulatory based provider education materials.
20% 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.
10% 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.
5% Assists in training of medical review associates regarding coverage and medical review process.
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 Work 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 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 others. Ability to handle confidential or sensitive information with discretion.
Required Software and Tools: Microsoft Office.
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).
Preferred Work Experience: 3 years-0f 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.
Work Environment: Typical office environment may involve travel between office buildings may involve travel to/from provider locations may involve travel within/outside of state.
Equal Employment Opportunity Statement
BlueCross 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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
If you need special assistance or an accommodation while seeking employment, please or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.
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