Payment Integrity Nurse – Medicare Advantage

Summary We are currently hiring for a Payment Integrity Nurse – Medicare Advantage to join BlueCross BlueShield of South Carolina. In this role as an Payment Integrity Nurse, you will monitor/implement quality improvement/management activities, conduct specific medical reviews as necessary, analyzes findings, makes recommendations for corrective actions, and prepares formal documentation for compliance with applicable standards/regulations, perform Health Plan Employer Data Information Set data collection (HEDIS), and National Committee for Quality Assurance (NCQA) accreditation activities. Description Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-4:30pm and will be fully remote after 4-8 weeks of on-site training. The candidate will be required to be on an on-call rotation with other nursing colleagues to cover weekends. What You’ll Do: Performs quality improvement activities to monitor/maintain compliance with applicable standards/regulations. Analyzes/documents/presents findings of quality improvement activities. Recommends corrective action and improvement when necessary. Conducts quality medical record reviews to monitor quality of care and service provided. Tracks/trends/investigates quality concerns and complaints. Coordinates HEDIS data collection. To Qualify for This Position, You'll Need the Following: Required Education: Associates in a job-related field Required Work Experience: 4 years clinical or behavioral health to include 2 years quality management experience. Required Skills and Abilities: Excellent verbal and written communication, customer service, organizational, presentation, problem solving, and analytical or critical thinking skills. Proficient spelling, grammar, punctuation, and basic business math. Ability to handle confidential or sensitive information with discretion. Demonstrated ability to identify the need for and implement corrective actions. Strong understanding of managed care. Required Software and Other Tools: Microsoft Office. Required Licenses and Certificates: Active, unrestricted licensure in Behavioral Health from the United States and in the state of hire, OR, 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, Registered Health Information Administrator (RHIA). (For DIV 4B ONLY, Active unrestricted LPN in state of hire.) We Prefer That You Have the Following: Ability to understand CMS guidance. Ability to persuade, negotiate, or influence others. Knowledge of mathematical or statistical concepts. Our Comprehensive Benefits Package Includes the Following: We offer our employees great benefits and rewards. You will be eligible to participate in the benefits for 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 [email protected] 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 . Some states have required notifications. Here's more information .