Sr. Provider Education Consultant

About the position As a Sr. Provider Education Consultant at CGS, you will play a crucial role in educating medical providers on various aspects of Medicare coverage, utilization statistics, documentation, and medical review processes. This position is fully remote, allowing you to work from home while engaging with providers across the country. Your primary responsibility will be to communicate and educate providers through various means, including written advisories, reports, letters, and telephone contacts. You will document all provider interactions in a tracking system to ensure accurate records and follow-up actions. In addition to direct communication, you will conduct formal conference calls and in-person educational visits with providers who are identified as over-utilizing services or have high denial and error rates under the medical review program. You will also be responsible for organizing and conducting coverage and documentation workshops for provider staff, ensuring they are well-informed about Medicare guidelines and documentation requirements. Your role will involve researching and preparing regulatory-based provider education materials, analyzing reports to determine necessary actions regarding medical reviews and audits, and identifying providers who are over-utilizing services. You will collaborate with the medical review department to provide insights on provider billing practices and participate in the medical review process, including inter-reviewer reliability studies. Additionally, you will assist in training medical review associates on coverage and medical review processes, contributing to the overall effectiveness of the team.

Responsibilities

• Communicates/educates providers on Medicare coverage, utilization statistics, documentation, and medical review.

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• Documents all provider contacts/communications in the provider tracking system.

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• Conducts formal conference calls and/or in-person educational visits with providers that are over-utilizing services or have unacceptable denial/error rates.

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• Conducts coverage and documentation workshops for provider staff.

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• Researches, composes, and coordinates the preparation of regulatory-based provider education materials.

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• Performs analysis of effective reports to determine actions regarding medical reviews/audits.

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• Identifies providers over-utilizing services and the specific services being over-utilized.

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• Collaborates with the medical review department to provide input on provider billing practices.

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• Targets providers with the greatest abuse of the Medicare program.

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• Participates in the medical review process and inter-reviewer reliability studies.

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• Assists in training medical review associates regarding coverage and medical review processes.

Requirements

• Graduate of accredited School of Licensed Practical Nursing (LPN), Licensed Vocational Nursing (LVN), or approved School of Nursing (RN).

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• If LPN or LVN, seven years of clinical experience or equivalent combination of clinical and educator experience.

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• If RN, five years of clinical experience or equivalent combination of clinical and educator experience.

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• Knowledge of medical terminology and disease processes.

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• Demonstrated proficiency in word processing and spreadsheet software.

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• Good judgment skills and effective customer service, organizational, and presentation skills.

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• Demonstrated proficiency in spelling, punctuation, and grammar.

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• Analytical or critical thinking skills.

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• Basic business math proficiency and knowledge of mathematical or statistical concepts.

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• Ability to persuade, negotiate, or influence others.

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• Ability to handle confidential or sensitive information with discretion.

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• Proficiency in Microsoft Office.

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• Active LPN, LVN, or RN licensure in the state hired or active compact multistate license as defined by the Nurse Licensure Compact.

Nice-to-haves

• Three years of provider relations and Medicare experience.

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• Knowledge of claims processing software.

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• In-depth knowledge of Medicare program guidelines and regulations governing coverage.

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• Working knowledge of Microsoft Access or other database software.

Benefits

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

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• Subsidized health plans and free vision coverage.

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• Life insurance.

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• Paid annual leave that increases with tenure.

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• Nine paid holidays.

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

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• Wellness programs and healthy lifestyle premium discount.

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• Tuition assistance.

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• Service recognition.

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• Incentive Plan.

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• Merit Plan.

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• Continuing education funds for additional certifications and certification renewal.

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