Provider Education & Consultation Consultant - LPN, LVN, or RN

Summary

Provides education to medical providers as warranted. Why should you join the Blue Cross Blue Shield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Palmetto GBA,– one of Blue Cross Blue Shield's South Carolina subsidiary companies.

This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

This a full-time remote position for the following areas: (South Carolina, North Carolina, Georgia, and Alabama)

You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.

-5:00 p.m. Monday - Friday. There will be some travel involved for in-person conferences and presentations. It may be necessary, given the business need to work occasional overtime.

• 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.

• 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.

• 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.