Senior Consultant, Provider Education
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Job Description
Senior provider educator helping Palmetto GBA, a BlueCross BlueShield South Carolina subsidiary, educate providers on Medicare coverage and medical review. Analyzing utilization and audits.
Responsibilities:
- Communicate and educate providers on Medicare coverage, utilization statistics, documentation, and medical review through advisories, reports, letters, and telephone contacts
- Document provider contacts and communications in the provider tracking system
- Conduct formal conference calls and in-person educational visits with providers over-utilizing services or having unacceptable denial or error rates
- Conduct coverage and documentation workshops for Medicare providers and physicians’ staff
- Research, compose, and coordinate regulatory-based provider education materials
- Analyze reports to determine actions regarding medical reviews and audits
- Determine which providers and services are being over-utilized
- Work with the medical review department and provide input on actions related to provider billing practices
- Target providers associated with the greatest Medicare program abuse
- Participate in the medical review process and inter-reviewer reliability studies
- Assist in training medical review associates on coverage and medical review processes
Requirements:
- Full-time remote position for candidates in South Carolina, North Carolina, Georgia and Alabama
- 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
- Knowledge of medical terminology and disease processes
- Proficiency in word processing and spreadsheet software
- Good judgment skills
- Customer service, organizational, and presentation skills
- 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
- Microsoft Office proficiency
- Active LPN or LVN licensure in state hired, active compact multistate LPN license under the Nurse Licensure Compact, active RN licensure in state hired, or active compact multistate RN license under the Nurse Licensure Compact
- Medicare experience preferred
- Knowledge of claims processing software preferred
- In-depth knowledge of Medicare program, guidelines, and regulations governing coverage preferred
- Working knowledge of Microsoft Excel, Microsoft Access, or other database software preferred
- No current or future sponsorship eligibility
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
- Diverse and inclusive workplace with opportunities to develop skills, advance careers and contribute unique abilities
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