(RN) Training and Quality Assurance Coordinator

SummaryCoordinates 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.Description• 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.• 5% 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.Required Education:Associate Degree - Nursing OR,Graduate of an Accredited School of Nursing.Required Work Experience:Four years combination of clinical, utilization review, training, quality assurance, or case management experience.Preferred Experience:Previous Quality and or Training experience.Previous Home Health and Hospice medical review.Prior clinical leadership experience.Prior Medical Reviewer III or above experience.Required Skills and Abilities:Excellent verbal and written communication, customer service, organizational, and analytical or critical thinking. Good judgment. Proficient spelling, grammar, punctuation, and basic business math. Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion. Knowledge of mathematical or statistical concepts and medical terminology.Required Software and Tools:Microsoft Office.Required License and Certificate:Active unrestricted RN licensure in state hired, OR, active unrestricted compact multistate RN license as defined by the Nurse Licensure Compact (NLC).We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Equal Employment Opportunity StatementBlueCross 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.We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.If you need special assistance or an accommodation while seeking employment, please e-mail [Click Here to Email Your Resumé] or call 1-800-288-2227, ext. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

Created: 2025-11-15