Urgently Need Quality Navigator – Healthy Blue Medicaid – Remote – Must Reside in SC in South Carolina

Job Description

Job title: Quality Navigator – Healthy Blue Medicaid – Remote – Must Reside in SC

Company: BlueCross BlueShield Of South Carolina

Job description: Summary

Abstracts and reviews 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

Logistics

• This position is full time (40 hours/week) Monday-Friday, 8:00 am – 4:30 OR 8:30 am – 5:00 pm,
• Position will be fully remote.
• Must have high speed internet (non-satellite) and private area for home office.
• Travel to provider offices to provide education and training will be required.
• Candidate must reside in South Carolina.

What You Will Do:

• Abstracts and reviews medical records for The Healthcare Effectiveness Data and Information Set (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.
• Participate 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:

• Associate’s degree- Nursing OR Graduate of Accredited School of Nursing OR Master’s degree in Social Work OR Master’s in Psychology, or Counseling OR Master’s in Health Care Administration.
• 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, active, unrestricted licensure as a pharmacy tech OR, unrestricted licensure as a social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as a counselor, or psychologist from the United States and in the state of hire.
• Four years of clinical experience including 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.
• Excellent verbal and written communication.
• Proficient spelling, grammar, punctuation, and basic business math.
• Customer service, organizational, presentation, problem-solving, and analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Demonstrate ability to identify the need for and implement corrective actions.
• Strong understanding of managed care.
• Microsoft Office, various provider EMRs, and database software.

What We Prefer

• Previous HEDIS and or provider education experience.
• Medical coding knowledge and/or experience.
• Pediatric and Behavioral Health experience.
• Two years of utilization medical review, quality assurance, or health insurance experience.
• Knowledge of claims systems.

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 can 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 the most qualified candidates.

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

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. 43172 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

Expected salary:

Location: South Carolina

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