HHH Senior Provider Education Consultant - CGS

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we have been part of the national landscape, 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 that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are committed to the same philosophy, consider joining our team!

Logistics: CGS Administrators - one of BlueCross BlueShield's South Carolina subsidiary companies.

Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. This is a Work at Home (W@H) position.

What You'll Do:

• Communicate and educate providers on issues such as Medicare coverage, utilization statistics, documentation and medical review by use of written advisories, reports, letters, and telephone contacts.
• Document all provider contacts and communications in provider tracking system.
• Conduct 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.
• Conduct coverage and documentation workshops for provider staff (Medicare providers and physicians' staff).
• Research, compose, and coordinate the preparation of all regulatory based provider education materials.
• Perform analysis of effective reports to determine actions to be taken regarding medical reviewed its and audits.
• Determine what providers are over-utilizing services and what services are being over-utilized.
• Work with medical review department and provide input regarding actions taken in response to provider billing practices.
• Target providers where greatest abuse of Medicare program has occurred.
• Participate in the medical review process and inter reviewer reliability (IRR) studies.
• Assist in training of medical review associates regarding coverage and medical review process.
• May involve travel between office buildings.
• May involve travel to and from provider locations.
• May involve travel within and outside of the state.

To Qualify for This Position, You'll Need:

• 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. (Can be concurrent)
• 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. In-depth knowledge of Medicare program instructions and regulations related to provider enrollment and issues. 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).
• Required Software and Tools: Must have experience with Microsoft Office.

We Prefer That You Have the Following:

• Preferred Skills and Abilities: Experience as a Medicare Administrative Contractor. Experience interpreting and educating others on medical policy. Experience interpreting data analytics Knowledge of claims processing software. In depth knowledge of Medicare program, guidelines, regulations governing coverage. Working knowledge of Microsoft Access or other database software.

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.

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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 to Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Pay Range Information:

Range Minimum

$61,617.00

Range Midpoint

$89,146.00

Range Maximum

$116,675.00

Pay Transparency Statement:

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information.

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 minorities, females, disabled individuals and 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 physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, 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.