Senior Provider Education Consultant - IRF RCD

033 Palmetto GBA; Georgia; Hybrid; USD 60,000 - 90,000; Full time

Benefits offered by this job

Subsidized health plans

Dental & vision coverage

401k retirement savings plan

Job summary

Palmetto GBA, a BlueCross BlueShield subsidiary, seeks a full-time provider educator to educate medical providers on Medicare coverage and documentation. The role includes travel across Alabama, Georgia, and Tennessee, with remote work supported.

You will document communications, conduct workshops, and coordinate regulatory materials. Required licensure (LPN/LVN/RN) and clinical experience, plus strong communication, analysis, and presentation skills.

Qualifications

• Must have active LPN/LVN or RN licensure in the hiring state
• Clinical educator experience preferred
• Knowledge of Medicare program guidelines and workflows
• Strong communication and presentation skills
• Ability to handle confidential information discreetly

Responsibilities

• Educates providers on Medicare coverage, utilization statistics, documentation, and medical review via advisories, reports, letters, and calls
• Documents provider contacts in the tracking system
• Conducts workshops for provider staff on coverage and documentation
• Leads formal calls or visits with high-utilization providers or high denial/error rates
• Develops educational materials and coordinates regulatory-based content
• Analyzes reports to determine actions in medical review processes
• Assists in training medical review staff on coverage and review processes
• Participates in IRR studies and provider engagement activities

Skills

Medical terminology

Communication

Word processing

Spreadsheet software

Customer service

Presentation skills

Analytical thinking

Confidentiality

Education

LPN licensure

LVN licensure

RN licensure

Tools

Microsoft Office

Provider tracking system

Microsoft Access

Job description

Summary

Provides education to medical providers as warranted.

Description Logistics

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

Location

This is a full-time remote position. You must reside in Alabama, Georgia, or Tennessee. You will work an 8-hour shift scheduled during our normal business hours of 8 a.m. - 5 p.m. Must be able to travel up to 3-5 days a week. There may be some weekday and weekend overnight traveling involved. May include travel outside of the assigned areas of Alabama, Georgia, or Tennessee as necessary.

Sponsorship

This position is not eligible for sponsorship now or in the future.

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 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.
• 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.
• Required Software and Tools: Microsoft Office.
• 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).

We Prefer That You Have the Following

• Preferred Work Experience: 3 years of provider relations and Medicare experience. IRF (Inpatient Rehabilitation Facility) education consultant 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

• 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.

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 [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. 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.

Palmetto GBA is a healthcare service administrator and one of the nation’s largest providers of high-volume medical claims and transaction processing. We provide services and technology solutions to improve and streamline healthcare administration not only for government but also for corporate entities. We offer a wide range of services that require a diverse workforce and expansive areas of expertise from data analytics, administrative and workflow services to advanced systems. To help our associates succeed and reach their professional goal, we offer training classes and programs that help employees prepare for leadership positions and offer tuition assistance for education advancement. Palmetto GBA acknowledges associates’ hard work and dedication with awards and financial incentives.