Summary
 

Ensures that the Local Coverage Determination (LCD) process adheres to contract instructions. Creates, implements, and maintains educational tools to help providers reduce the submission of claims for non-covered services and reduce the claims payment error rate. The error rate is a factor in awarding and renewing Medicare/other contracts.

Description
 

Logistics

This position is full time (40 hours/week) Monday-Friday 8:00-5:00 and will be W@H.

Unrestricted RN license required

What You Will Do:

• Provides clinical expertise, research, and judgment to develop Local Coverage Determinations(LCDS) under the direction of medical director. Maintains LCDS once developed.

• Educates providers and internal customers on LCDS. Communicates with other interdepartmental staff in appropriate coding and reimbursement guidelines to ensure coordination and compliance.

• Provides clinical input for internal requests. Serves as reviewer to determine inter-rater reliability.

To Qualify for This Position, You Will Need:

• Bachelor's in a job related field OR Graduate of Accredited School of Licensed Practical Nursing or Licensed Vocational Nursing

• Required Work Experience: 5 years clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.

• Required Skills and Abilities: Knowledge of managed care or medical claims payment policy issues. Working knowledge of word processing, spreadsheet software. Excellent verbal and written communication skills. Excellent customer service, organizational, presentation, analytical or critical thinking skills. Ability to persuade, negotiate, or influence others. Ability to handle confidential or sensitive information with discretion.

• Required Software and Tools: Microsoft Office.

• Required License and Certificate: An active, unrestricted RN license 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). For Division 33, Certified Genetic Counselor will be considered in lieu of RN License.

What We Prefer:

• Bachelor's degree- Nursing.

• 7 years-clinical experience in medical insurance, managed care, case management, or claims management, or a combination of these areas.

• Preferred Skills and Abilities: Working knowledge of database software. Knowledge of government/healthcare programs and contracts laws, regulations. Knowledge of government/healthcare programs and regulations, coding, and approval practices. Knowledge of corporate administrative/medical policy for all lines of business. Knowledge of guidelines, benefits, and coverage for all lines of business.
  Preferred Software and Tools: Working knowledge of Microsoft Access or other database software, DB2 and Easytrieve.

• Preferred Licenses and Certificates: HIAA, Loma, and/or ACLI certification. MPH, MHA certifications.

• Experience with molecular testing

• Experience with policy work

What We Can Do for You:

• 401(k) retirement savings plan with company match.

• Subsidized health plans and free vision coverage.

• Life insurance.

• Paid annual leave – the longer you work here, the more you earn.

• Nine paid holidays.

• On-site cafeterias and fitness centers in major locations.

• Wellness programs and healthy lifestyle premium discount.

• Tuition assistance.

• Service recognition.

• Incentive Plan.

• Merit Plan.

• Continuing education funds for additional certifications and certification renewal.

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.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

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