Payment Integrity Nurse – Medicare Advantage

BlueCross BlueShield of South Carolina•W@H South Carolina, SC

5d•Hybrid

About The Position

We are currently hiring for a Payment Integrity Nurse – Medicare Advantage to join BlueCross BlueShield of South Carolina. In this role as an Payment Integrity Nurse, you will monitor/implement quality improvement/management activities, conduct specific medical reviews as necessary, analyzes findings, makes recommendations for corrective actions, and prepares formal documentation for compliance with applicable standards/regulations, perform Health Plan Employer Data Information Set data collection (HEDIS), and National Committee for Quality Assurance (NCQA) accreditation activities. This position is full-time (40 hours/week) Monday-Friday from 8:00am-4:30pm and will be fully remote after 4-8 weeks of on-site training. The candidate will be required to be on an on-call rotation with other nursing colleagues to cover weekends.

Requirements

Associates in a job-related field
4 years clinical or behavioral health to include 2 years quality management experience.
Excellent verbal and written communication, customer service, organizational, presentation, problem solving, and analytical or critical thinking skills.
Proficient spelling, grammar, punctuation, and basic business math.
Ability to handle confidential or sensitive information with discretion.
Demonstrated ability to identify the need for and implement corrective actions.
Strong understanding of managed care.
Microsoft Office.
Active, unrestricted licensure in Behavioral Health from the United States and in the state of hire, OR, active, unrestricted RN licensure from the United States and in the state of hire OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR, Registered Health Information Administrator (RHIA). (For DIV 4B ONLY, Active unrestricted LPN in state of hire.)

Nice To Haves

Ability to understand CMS guidance.
Ability to persuade, negotiate, or influence others.
Knowledge of mathematical or statistical concepts.

Responsibilities

Performs quality improvement activities to monitor/maintain compliance with applicable standards/regulations.
Analyzes/documents/presents findings of quality improvement activities.
Recommends corrective action and improvement when necessary.
Conducts quality medical record reviews to monitor quality of care and service provided.
Tracks/trends/investigates quality concerns and complaints.
Coordinates HEDIS data collection.