Summary
 

We are currently hiring for a Quality Navigator to join BlueCross BlueShield of South Carolina. In this role as the Quality Navigator, you will abstract and review medical records for HEDIS (Health Plan Employer Data Information Set) for both prospective and retrospective seasons to ensure that our Company complies with NCQA (National Committee for Quality Assurance) standards and achieve its CMS (Centers for Medicare & Medicaid Services) Star rating. You will perform quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations, educate network providers on HEDIS clinical measures and coding accuracy, and be responsible for continuing education on HEDIS/NCQA measures while performing/coordinating HEDIS data collection, and NCQA accreditation activities.

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Here is your opportunity to join a dynamic team at a diverse company with secure, community roots and an innovative future.

Description
 

Logistics

This position is full time (40 hours/week) Monday-Friday, 8:00am–4:30pm OR 8:30am–5:00pm, and will be fully remote (W@H); candidate must reside in South Carolina.

What You Will Do:

• Abstracts and reviews medical records for HEDIS for both prospective and retrospective seasons to ensure that our Company complies with NCQA standards and achieves its CMS Star rating.

• Researches and stays up to date on all HEDIS clinical measures and NCQA standards/guidelines.

• Performs quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations.

• Tracks/trends/investigates quality concerns and complaints.

• Educates network providers on HEDIS clinical measures and coding accuracy.

• Keeps providers up to date on HEDIS clinical measures.

• Works with providers to collect medical records and provides support to close gaps in care.

• Recommends corrective action OR improvement to providers when necessary.

• Develops training materials for provider education.

• Participates in other assigned projects.

• Performs/coordinates HEDIS data collection and NCQA accreditation activities.

• Responsible for continuing education on HEDIS/NCQA measures.

• Provides HEDIS training for new employees.

To Qualify for This Position, You Will Need:

• Associates in a job-related field.

• Four years-clinical experience to include two years of experience in a clinical area providing patient care.

• Excellent verbal and written communication, customer service, organizational, presentation, problem so