Senior Employee Benefits Consultant
The Standard
Senior Provider Education Consultant
BlueCross BlueShield of South Carolina
full-time
Posted on:
Location Type: Remote
Location: Remote • Alabama, North Carolina, South Carolina, Tennessee • 🇺🇸 United States
Visit company websiteJob Level
Senior
About the role
- 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
- 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.
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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical terminologydisease processesword processingspreadsheet softwarebusiness mathanalytical skillscritical thinkingpersuasionnegotiationinfluence
Soft skills
customer serviceorganizational skillspresentation skillsgood judgmentdiscretion
Certifications
LPN licensureLVN licensureRN licensurecompact multistate LPN licensecompact multistate RN license
