Summary
 

Provides education to medical providers as warranted.

Description
 

What You’ll Do:

• Communicate and educate providers on issues such as Medicare coverage, utilization statistics, documentation and medical review by use of written advisories, reports, letters, and telephone contacts.
• Document all provider contacts and communications in the provider tracking system.
• Conduct 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.
• Conduct coverage and documentation workshops for provider staff (Medicare providers and physicians' staff).
• Research, compose, and coordinate the preparation of all regulatory based provider education materials.
• Perform analysis of effective reports to determine actions to be taken regarding medical reviews / audits.
• Determine what providers are over-utilizing services and what services are being over-utilized.
• Work with the medical review department and provide input regarding actions taken in response to provider billing practices.
• Target providers where greatest abuse of Medicare program has occurred.
• Participate in the medical review process and enter reviewer reliability (IRR) studies.
• Assist in training of medical review associates regarding coverage and medical review processes.
• May involve travel between office buildings or traveling to and from provider locations.
• May involve travel outside of the state.
• This position has the ability to be remote.

To Qualify for This Position, You’ll Need:

• An active LPN or LVN license in the state hired OR an active compact multistate LPN license and seven years of clinical experience OR equivalent combination of clinical and educator experience.
• An active RN license in the state hired OR an active compact multistate RN license and five years of clinical experience OR equivalent combination of clinical and educator experience.
• 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.
• In-depth knowledge of Medicare program instructions / regulations related to provider enrollment issues.
• Microsoft Office.

What We Prefer:

• Three years of Provider Relations and Medicare experience.
• Knowledge of claims processing software.
• In-depth knowledge of Medicare program, guidelines, regulations governing coverage.
• Working knowledge of Microsoft Access or other database software.

What We can Do for You:

• 401(k) retirement savings plan with company match.
• Subsidized health plans and free vision coverage.
• Life insurance.
• Paid annual leave – the longer you work here, the more you earn.
• Nine paid holidays.
• On-site cafeterias and fitness centers in major locations.
• Wellness programs and healthy lifestyle premium discount.
• Tuition assistance.
• Service recognition.
• Incentive Plan.
• Merit Plan.
• Continuing education funds for additional certifications and certification renewal.

What to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure your 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 the most qualified candidates, with prioritization give 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.

Some states have required notifications. Here's more information. 

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 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 [email protected] or call 1-800-288-2227, 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.