[Hiring] Payment Integrity Nurse @BlueCross BlueShield of South Carolina

Role Description

We are currently hiring for a Payment Integrity Nurse – Medicare Advantage to join BlueCross BlueShield of South Carolina. In this role as a Payment Integrity Nurse, you will:

• Monitor/implement quality improvement/management activities.
• Conduct specific medical reviews as necessary.
• Analyze findings and make recommendations for corrective actions.
• Prepare formal documentation for compliance with applicable standards/regulations.
• Perform Health Plan Employer Data Information Set data collection (HEDIS).
• Participate in National Committee for Quality Assurance (NCQA) accreditation activities.

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.

Qualifications

• Associates in a job-related field.
• 4 years clinical or behavioral health experience, including 2 years quality management experience.
• 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.

Requirements

• 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.)

Benefits

• 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.