Senior Medical Review Provider Consultant – RN Position Available In Spartanburg, South Carolina

Summary Provides education to medical providers as warranted.

Description Logistics:

Palmetto GBA,- one of BlueCross BlueShield’s South Carolina subsidiary companies.

Location:

This position is full-time Remote (40-hours/week) Monday-Friday in South Carolina. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. There will be some travel involved for in-person conferences and presentations. It may be necessary, given the business need to work occasional overtime. This role is 100% remote in South Carolina only.

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 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 email mycareer.help@bcbssc.com 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. Some states have required notifications. Here’s more information. If you don’t have an account with us and don’t see the dream job you are looking for, click on the link above to Join Our Talent Community by submitting your resume and contact information and we will reach out if we find a good fit. Welcome Here’s Your Smart Career Move Why should you join the BlueCross BlueShield of South Carolina family of companies? 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. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating. We’re 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! Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty. Join Us If you’re ready to join in a diverse company with secure, community roots and an innovative future, apply for a position now!