Provider Educator & Medicare Risk Adjustment Coder (W@H SC, NC, GA, TN, FL)

001 BlueCross and BlueShield of South Carolina; South Carolina; Ibrido; USD 90.000 - 120.000; Tempo pieno

Vantaggi offerti da questo lavoro

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off

Education Assistance

Service Recognition

National discounts

Descrizione del lavoro

BlueCross BlueShield of South Carolina is hiring a Provider Educator & Medicare Risk Adjustment Coder. This role monitors and collects Medicare Stars data to improve health plan ratings and conducts medical record reviews to inform corrective actions.

The position supports HEDIS and NCQA accreditation activities, requires strong data analysis, and adherence to HIPAA. It is full-time, primarily remote with occasional on-site trainings.

Competenze

• Requires Bachelor's in a job-related field.
• 4 years job related work experience or Associate's and 2 years job related work experience.
• Professional certification in nursing, pharmacy, medical assistant, or related certs (CPHQ, AHM, HIM, CRC) required.
• Minimum 2 years of managed care, quality improvement, medical research, or clinical experience.
• Must be familiar with HEDIS standards and Medicare Advantage.

Mansioni

• Coordinate HEDIS and Star data collection using analytics and medical records.
• Enter and review Star measure data per NCQA/CMS specs.
• Oversight of external data sources and vendors.
• Use Star data to identify opportunities and support Stars program initiatives.

Conoscenze

Independent work

Analytical thinking

Communication skills

HIPAA compliance

Formazione

Bachelor's degree in a job-related field

Strumenti

HEDIS data systems

Tableau

Microsoft Excel

NCQA standards

Descrizione del lavoro

Summary

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, 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, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

We are currently hiring for a Provider Educator & Medicare Risk Adjustment Coder to join BlueCross BlueShield of South Carolina. In this role as a Provider Educator & Medicare Risk Adjustment Coder, you will monitor and collect Medicare Stars data to improve health plan ratings, conduct specific medical record reviews, analyze findings, make recommendations for corrective actions, prepare formal documentation for compliance with applicable standards/regulations, and perform Health Plan Employer Data Information Set data collection (HEDIS), and National Committee for Quality Assurance (NCQA) accreditation activities.

Location

This position is full-time (40 hours/week) Monday-Friday with an 8-hour shift between 7:00am-9:00pm and will be fully remote. The candidate may be required to come on-site for occasional trainings, meetings, or other business needs. Sponsorship: This position is not eligible for sponsorship now or in the future.

What You’ll Do

• Coordinates HEDIS and Star measure data collection using analytic resources, paper records, electronic medical charts and other authorized resources.
• Conducts data entry and review of Star measure data in accordance with NCQA and CMS technical specifications.
• Maintains oversight of external data sources and vendors.
• Use available Stars data to identify opportunities for improvement and support the development of Stars program initiatives.

Qualifications

• Required Education: Bachelor's in a job-related field
• Degree Equivalency: 4 years job related work experience or Associate's and 2 years job related work experience
• Required Specialized Training: Professional certification in nursing, pharmacy, medical assistant, other healthcare training. OR – Certified professional in Healthcare Quality (CPHQ) certificate, Academy for Health Care Management (AHM) certificate, Health Information Management (HIM) certificate, Certified Risk Adjustment Coder (CRC) certificate or other related certification.
• Required Work Experience: Minimum 2 years of managed care, quality improvement, medical research or clinical experience. Minimum 2 year working with HEDIS standards, quality measures, and Medicare Advantage (can be concurrent). Must be familiar with clinical terminology, and reading paper/electronic medical records.
• Required Skills and Abilities: Ability to work independently with a detailed focus on paper/electronic medical information and other sources to extract needed data for Medicare Star ratings. Ability to understand and follow HEDIS NCQA, HOS, CAHPS, Pharmacy and Star measure data requirements. Must maintain HIPPA compliance and quality standards. 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.

Preferred

• Preferred Education: Bachelor's degree in healthcare, healthcare administration, or health sciences, or four years of related work experience.
• Preferred Specialized Training: Experience with Medicare Stars, HEDIS, Pharmacy data, NCQA, CAHPS, HOS, Medicare Stars methodology, risk adjustment, medical records and data analysis.
• Preferred Work Experience: Experience with Retrospective chart review, Prospective gap validation (preferred), and RADV audits or audit preparation (highly preferred) Minimum 4+ years of managed care, quality improvement, medical research or clinical experience. Minimum 3+ years working with HEDIS standards, quality measures, and Medicare Advantage (can be concurrent).
• Preferred Skills and Abilities: Strong understanding of HCC and RxHCC models, Medicare Advantage risk adjustment methodology, and encounter data and claims submission processes (e.g., EDPS familiarity preferred) Ability to persuade, negotiate, or to influence others. Knowledge of mathematical or statistical concepts.
• Preferred Certifications: CPC, CRC, CCS, or equivalent
• Preferred Software and Other Tools: Prefer experience with data/analytic platforms such as hybrid tools, HEDIS engines, supplemental data sources, electronic medical records, Tableau, Microsoft Access, and Microsoft Excel.

Benefits

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

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 individuals with disabilities and protected 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 disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 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. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.