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

Southcarolinablues; South Carolina; Teletrabalho; USD 70 000 - 110 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Health insurance

Dental and vision coverage

401k with company match

Life Insurance

Paid Time Off

Education assistance

Service recognition

National discounts

Resumo da oferta

BlueCross BlueShield of South Carolina is hiring a Provider Educator & Medicare Risk Adjustment Coder to monitor and improve Medicare Stars data. The role involves data collection and chart reviews to support compliance with NCQA/CMS standards, plus data-driven actions to enhance health plan ratings.

The position is fully remote with a 40-hour workweek, Monday–Friday. A Bachelor's degree plus healthcare-related certification is required; CRE/CRC/CPC or equivalent is preferred.

Qualificações

• Bachelor's in a job-related field.
• 4 years of job-related work experience or 2 years with an Associate's degree.
• Professional certification in healthcare quality or CRC/CPC or related certificate.
• Minimum 2 years in managed care, quality improvement, medical research, or clinical work.
• Experience with HEDIS standards, Medicare Advantage, and STAR data.

Responsabilidades

• Coordinate HEDIS and Star data collection using analytic, paper, and EMR sources.
• Enter and review Star data per NCQA/CMS specs and ensure data quality.
• Oversee external data sources and vendors involved in data submission.
• Identify improvement opportunities using Stars data and support initiatives.
• Ensure HIPAA compliance and high-quality data handling.

Conhecimentos

Independent work

Analytical thinking

Verbal and written communication

HIPAA compliance

Data extraction

Problem solving

Formação académica

Bachelor's in a job-related field

Ferramentas

Tableau

Microsoft Excel

Microsoft Access

Descrição da oferta de emprego

## Provider Educator & Medicare Risk Adjustment Coder (W@H SC, NC, GA, TN, FL)Apply: Remote: W@H South Carolina: Full time: Posted Today: End Date: November 12, 2026 (14 days left to apply): R1052585# **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.# **Description****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.**To Qualify for This Position, You'll Need the Following:*** **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 andquality 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.**We Prefer That You Have the Following:*** **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.**Our Comprehensive Benefits Package Includes the Following:**We offer our employees great benefits and rewards. You will be eligible to participate in the benefits for the first of the month following 28 days of employment. * 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.**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 our recruiter to verify resume specifics and salary requirements. Management will conduct interviews with those candidates who qualify, with prioritization given to those candidates who demonstrate the preferred qualifications.**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.