Summary
 

We are currently hiring for a Quality Navigator to join BlueCross BlueShield of South Carolina. In this role as a 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 achieves its CMS (Centers for Medicare & Medicaid Services) Star rating. Performs quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations. Educates network providers on HEDIS clinical measures and coding accuracy. Responsible for continuing education on HEDIS/NCQA measures. Performs/coordinates HEDIS data collection, and NCQA accreditation activities.

Description
 

Location:

This position is full-time (40-hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote but the candidate must reside South Carolina.

What You’ll 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'll Need the Following:

• Required Education:  Associates in a job-related field
• Required Work Experience: 4 years-clinical experience to include 2 years of experience in a clinical area providing patient care.
• Required Skills and Abilities: 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.
• Required Software and Other Tools: Microsoft Office, various provider EMRs, and database software.
• Required Licenses and Certificates: 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).

We Prefer That You Have the Following:

• Preferred Education: Bachelor’s degree – Nursing
• Preferred Work Experience: Clinical quality experience
• Prefe