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

BlueCross and BlueShield of South Carolina; United States; Remote; USD 80.000 - 110.000; Vollzeit

Zusammenfassung

BlueCross BlueShield of South Carolina is seeking a Provider Educator & Medicare Risk Adjustment Coder to monitor and collect Medicare Stars data, perform records reviews, analyze findings, and develop corrective actions. The role also includes data collection for HEDIS and NCQA accreditation activities.

The candidate will work in a full-time, remote setting with occasional on-site trainings. Sponsorship is not available for this position.

Qualifikationen

• Bachelor's degree in a job-related field.
• Minimum 2 years of managed care, quality improvement, medical research or clinical experience.
• Minimum 2 years working with HEDIS standards, quality measures, and Medicare Advantage.

Aufgaben

• Coordinate HEDIS and Star measure data collection using analytic resources and medical records.
• Conduct data entry and review of Star measure data per NCQA & CMS specs.
• Maintain oversight of external data sources and vendors; monitor data quality.
• Identify improvement opportunities and support Stars program initiatives.

Kenntnisse

Attention to detail

Analytical thinking

Communication

Independent work

Healthcare terminology

Ausbildung

Bachelor's degree

4 years related work experience or Associate's + 2 years

Jobbeschreibung

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 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.

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