Consultant, Sr Provider Education

BlueCross BlueShield of South Carolina•Nashville, TN

32d•Hybrid

About The Position

Summary Provides education to medical providers as warranted. Description Logistics: CGS (cgsadmin.com) – one of BlueCross BlueShield's South Carolina subsidiary companies. Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen. Location: This a hybrid position. Onsite work will be performed at 26 Century Blvd. Nashville, TN 37214. You will work an 8-hour shift scheduled during our normal business hours of 8:00 a.m.-5:00 p.m. Monday - Friday . 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.

Requirements

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) others.
Ability to handle confidential or sensitive information with discretion.
This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Nice To Haves

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.

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.