Internal Reference Number: R1046743 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

Location This role is remote, full time M-F 8am-5pm.

Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O'Hara Service Contract Act (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.

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:

Required Education: Bachelor's in a job related field OR Associate's degree in Nursing with an active RN license.

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

Required Software and tools: Microsoft Office

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 License and Certificate: 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:

Preferred Education: Bachelor's degree- Nursing.

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

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.

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.

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

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 a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications. 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 disabilitiesand 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.comor 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 moreinformation.

Some states have required notifications. Here's more information.

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 minorities, females, disabled individuals and 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.

BlueCross BlueShield of South Carolina

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