Senior Medical Review Provider Consultant - RN

BlueCross BlueShield of South Carolina; Columbia (SC); On-site; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Sr. Provider Education Consultant to enhance provider education and compliance. This role involves educating medical providers about Medicare coverage and documentation, conducting workshops, and analyzing provider performance. The ideal candidate will have a strong clinical background, excellent communication skills, and a passion for educating others. Join a dynamic team that values diversity and inclusion, and enjoy a comprehensive benefits package that supports your professional growth and well-being.

Benefits

Subsidized health plans

401k retirement savings plan

Life Insurance

Paid Time Off (PTO)

On-site cafeterias

Education Assistance

Service Recognition

National discounts

Qualifications

• 7 years of clinical experience for LPN/LVN or 5 years for RN.
• Proficiency in word processing and spreadsheet software.

Responsibilities

• Educate providers on Medicare coverage and documentation.
• Conduct workshops and analyze provider performance.

Skills

Knowledge of medical terminology

Effective customer service

Organizational skills

Presentation skills

Analytical skills

Education

Graduate of accredited School of Nursing

Active LPN or RN licensure

Tools

Microsoft Office

Claims processing software

Microsoft Access

Job description

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Sr. Provider Education Consultant

Apply remote type On-site locations Columbia, South Carolina time type Full time posted on Posted Yesterday time left to apply End Date: May 30, 2025 (22 days left to apply) job requisition id R1044560

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 (40-hours/week) Monday-Friday in a typical office environment. 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 located at 17 Technology Circle Columbia, SC, 29203.

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 LVNlicensure 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 disabilitiesand 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 [e-mail] 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.

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