Summary
 

We are currently hiring for a Clinical Training and QA Coordinator to join BlueCross BlueShield of South Carolina. In this role as Clinical Training and QA Coordinator, you will coordinate the quality control program for the medical review area, researches the Center for Medicare and Medicaid services (CMS) changes, and train new staff while providing continuing education to clinical staff.

This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years.

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 8:00-4:30PM CST and will be W@H OR On-site at One Century Plaza, Nashville TN.

What You Will 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 Will Need:

• Associate's in a job related field OR Graduate of Accredited School of Nursing
• Four years combination of clinical, utilization review, training, quality assurance, or case management experience.
• 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 Tools: Microsoft Office.
• Required Licenses and Certificates: Active unrestricted RN licensure in state hired, OR, active unrestricted compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

What We Prefer You Have:

• Utilization Review / Medical Review experience.
• MCS System Knowledge.
• Medicare Part B.

• CMS Knowledge.
• Knowledge of claims systems.
• Ability to effectively use Microsoft Office applications, such as Word, Power point and Exc