Summary
 

We are currently hiring for a Sr. Provider Education Consultant to join CGS family. In this role as Sr. Provider Education Consultant, you will provide education to medical providers as warranted.

Why should you join the CGS and our parent company BlueCross BlueShield of South Carolina family? Other companies come and go, but for more than seven decades we’ve 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 dedicated to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics

This position is full time (40 hours/week) Monday-Friday and will be fully remote (W@H).

What You Will 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.

To Qualify for This Position, You Will Need:

• 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, seven years of clinical experience OR equivalent combination of clinical and educator experience.

• If RN, five years of clinical experience or equivalent combination of clinical and educator experience.

• 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.