Provides education to medical providers as warranted.
- 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.
- 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.
Preferred Work Experience:
- Three years of provider relations and Medicare Part B 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.
- Strong written and oral communications skills
- Ability to have a flexible schedule to meet client needs
Preferred Skills and Abilities:
- Knowledge of claims processing software.
- In-depth knowledge of Medicare program, guidelines, regulations governing coverage.
Required Software and Tools:
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).
- Infrequent travel up to 20% including overnight.
- If needed, flexible work hours that may include early mornings, evenings, and weekends may be warranted to meet client need.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
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 firstname.lastname@example.org or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.