Quality Navigator

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 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.

• Microsoft Office, various provider EMRs, and database software.

• 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).

What We Prefer

• Bachelor’s degree – Nursing.

• Two years of utilization medical review, quality assurance, and home health experience.

• Two years of health insurance experience.

• Knowledge of the National Committee for Quality Assurance (NCQA).

• Knowledge of Utilization Review Accreditation Commission (URAC).

• Knowledge of the South Carolina Department of Insurance (SCDOI).

• Knowledge of US DOL and Health Insurance.

• Portability/Accountability Act (HIPAA) standards/regulations.

• Excellent organizational and time management skills.

• Knowledge of claims systems.

• Presentation skills.

• Previous HEDIS, provider education, and medical coding experience.

What We Can Do for You

• 401(k) retirement savings plan with company match.

• Subsidized health plans and free vision coverage.

• Life insurance.

• Paid annual leave – the longer you work here, the more you earn.

• Nine paid holidays.

• On-site cafeterias and fitness centers in major locations.

• Wellness programs and healthy lifestyle premium discount.

• Tuition assistance.

• Service recognition.

• Incentive Plan.

• Merit Plan.

• Continuing education funds for additional certifications and certification renewal.

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview OR email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information. 

Equal Employment Opportunity Statement

BlueCross 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 [email protected] or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.