Summary
Provides education to medical providers as warranted.
Description
Position Purpose: The Sr. Provider Education Consultant will be responsible for communicating with healthcare providers about the TPE (Targeted Probe and Educate) process, supporting medical review activities, developing educational materials, and helping providers understand and comply with Medicare requirements. They will contact physicians, hospitals, clinics, or other healthcare providers when they have been selected for a TPE review, explaining why they were selected, and provide guidance on documentation requirements and next steps.
Logistics: Palmetto GBA – one of BlueCross BlueShield's South Carolina subsidiary companies.
Location: This a full-time remote position. You will work an 8-hour shift scheduled during our normal business hours of 8:30 a.m. – 5 p.m. EST.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You'll 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'll Need the Following
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 Work 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 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 others.
- Ability to handle confidential or sensitive information with discretion.
Required Software and Tools
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),
- Active RN licensure in state hired OR active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).
We Prefer That You Have the Following
Preferred Work Experience
Preferred Skills and Abilities
- Knowledge of claims processing software. In-depth knowledge of Medicare program, guidelines, regulations governing coverage.
Preferred Software and Other Tools
- Working knowledge of Microsoft Excel or other database software.