RN Training and Quality Assurance Coordinator (Remote)

We are currently hiring for an RN Training and Quality Assurance Coordinator to join BlueCross BlueShield of South Carolina. In this role as an RN Training and Quality Assurance Coordinator, you will coordinate the quality control program for the medical review area. Researches the Center for Medicare and Medicaid services (CMS) changes. Trains new staff and provides continuing education to clinical staff. This open position is within one of our subsidiary companies called CGS Administrators. CGS has been a proven provider of administrative and business services for state Medicaid agencies, managed care organizations, commercial health plans, Medicaid members, Medicare beneficiaries, healthcare providers, and medical equipment suppliers for more than 50 years. Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future. Logistics: This position is full-time (40 hours/week) Monday-Friday from 8:00 am-4:30 pm CST and will be fully remote.

Reviews medical review decisions for accuracy and to ensure CMS instructions have been applied correctly. Develops/implements the quality control program used as an intense review of clinical staff's technical knowledge and evaluation of medical judgment ability. Provides feedback to management and staff, and, if necessary, provides remedial training. Assists provider service departments with medical coverage issues to ensure continuity of application of CMS guidelines. Responds to specific provider inquiries and appeals requests. Develops and maintains departmental reference manuals used for proper application of CMS instructions. Provides continuing education workshops on coverage issues and medical advances. Trains new staff on CMS guidelines and medical review procedures. Coordinates system access and security clearance of new staff. Creates monthly reports for management outlining quality control results, adjustment data, and reopen results summary. Provides input to medical review audit department regarding actions taken in response to provider billing practices in order to target program abuse.