Apply on Employer Site

BlueCross BlueShield of South Carolina · 23 hours ago

Consultant, Sr Provider Education

United States

Full-time

Remote

Senior Level

5+ years exp

BlueCross BlueShield of South Carolina is seeking a Senior Provider Education Consultant to provide education to medical providers. The role involves communicating with providers on Medicare issues, documenting communications, conducting educational workshops, and participating in the medical review process.

Financial ServicesHealth CareHealth InsuranceInsuranceMedical

No H1B

Security Clearance Required

U.S. Citizen Only

Responsibilities

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

Qualification

Medicare knowledgeClinical experienceProvider educationMicrosoft OfficeClaims processing softwareJudgmentCustomer serviceAnalytical skillsOrganizational skillsPresentation skillsNegotiation skills

Required

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, 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

Microsoft Office

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

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)

Ability to handle confidential or sensitive information with discretion

Preferred

3 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

Benefits

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

Company

BlueCross BlueShield of South Carolina

Glassdoor3.6

For more than six decades, BlueCross BlueShield of South Carolina has been part of the national landscape. Our roots are firmly embedded in the state.

Founded in 1946

Columbia, South Carolina, USA

10001+ employees