Offer summary

Qualifications:

Associate degree in Nursing or graduate of an accredited School of Nursing., Four years of experience in clinical, utilization review, training, quality assurance, or case management., Excellent verbal and written communication skills, along with strong organizational and analytical abilities., Active, unrestricted RN licensure from the United States and in the state of hire. .

Key responsibilities:

Coordinate the quality control program for medical review and provide feedback based on quality audits.

Develop and deliver training for new staff and continuing education for clinical staff.

Create monthly reports for management on quality control results and other relevant data.

Assist provider service departments with medical coverage issues and respond to provider inquiries.

Job description

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 Tools: Microsoft Office.
Software and Tools: Microsoft Office.
License: Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), OR current active, unrestricted licensure/certification from the United States and in the state of hire in specialty area as required by hiring division/area.

What We Prefer You Have:

Education: Bachelor's degree in nursing (BSN)
Work Experience: Experience with Home Health, Hospice, CMS, Iflow, IRR systems, strongly preferred.
Skills and Abilities: Excellent presentation skills. Attention to detail.
Software and Tools: Ability to use multiple Windows-based programs simultaneously. Intermediate Excel skills. Ability to create training presentations in Powerpoint.

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 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.

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.

Equal Employment Opportunity Statement

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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 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.

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