Summary
 

We are currently hiring for a Sr. Provider Education Consultant to join CGS family. In this role as Sr. Provider Education Consultant, you will provide education to medical providers as warranted.

Why should you join the CGS and our parent company BlueCross BlueShield of South Carolina family? 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!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics

This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H).

What You Will 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 Will Need:

• 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.

• If LPN OR LVN, seven years of clinical experience OR equivalent combination of clinical and educator experience.

• If RN, 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.

• Microsoft Office.

• 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).

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 you meet the qualifications. This may include a brief telephone interview or email communication with a 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.

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.