Summary
 

We are looking for an experienced Medical Reviewer to join the Home Health and Hospice Medicare review team as a Training and Quality Assurance Coordinator.

Position Purpose:
Coordinates the quality control program for the medical review area. Provides feedback and additional training to staff based on quality audits. Researches the Center for Medicare and Medicaid services (CMS) changes. Once process or policy changes or additions are identified, develops staff training using PowerPoint. Trains new staff and provides continuing education to clinical staff. Reviews, updates and develops Excel spreadsheets. Provides spreadsheets and reports to CMS.

Position will require four to six weeks of virtual training.

Description
 

Logistics:

Palmetto GBA https://corporate.palmettogba.com/ – one of BlueCross BlueShield’s South Carolina subsidiary companies.

Location:

• Palmetto GBA is a flexible organization and available working hours are between 8:00 am – 5:30 pm EST Monday through Friday.  It is expected that each associate’s daily workday consists of an 8.5 hour day which includes 8 hours work time and 30 minutes for lunch. Occasional work beyond these hours may be required.

• To work from home, you must have high-speed (non-satellite) internet service and a private home office.

• May require travel to Columbia, SC office based on needs of the Medical Review Training Department.

What You'll Do:

• Reviews medical review decisions for accuracy and to ensure CMS instructions have been applied correctly.

• Develops/implements the quality control program used as an intense review of clinical staff's technical knowledge and evaluation of medical judgment ability. Provides feedback to management and staff, and, if necessary, provides remedial training.

• Assists provider service departments with medical coverage issues to ensure continuity of application of CMS guidelines. Responds to specific provider inquiries and appeals requests.

• Develops and maintains departmental reference manuals used for proper application of CMS instructions.

• Provides continuing education workshops on coverage issues and medical advances.

• Trains new staff on CMS guidelines and medical review procedures. Coordinates system access and security clearance of new staff.

• Creates monthly reports for management outlining quality control results, adjustment data, and reopen results summary.

• Provides input to medical review audit department regarding actions taken in response to provider billing practices in order to target program abuse.

To Qualify for This Position, You'll Need:

• Education: Associate degree - Nursing OR Graduate of an accredited School of Nursing.

• Work Experience: Four years combination of clinical, utilization review, training, quality assurance, or case management experience.

• Required Skills and Abilities: Excellent verbal and written communication, customer service, organizational, and analytical or critical thinking. Good judgment. Proficient spelling, grammar, punctuation, and basic business math. Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion. Knowledge of mathematical or statistical concepts and medical terminology.

• Required Software and