Quality and Performance Consultant

Health Care Service Corp.; Brooklyn Heights (TN); On-site; USD 42,000 - 93,000; Full time

Benefits offered by this job

Health benefits

401(k) savings plan

Pension plan

Paid time off

Paid parental leave

Disability insurance

Employee assistance program

Tuition reimbursement

Job summary

Health Care Service Corporation (HCSC) is seeking a Quality Analyst to perform trending analyses of quality results and coordinate QOC case intake, triage and tracking. The role includes drafting executive summaries, coordinating with internal partners, and focusing on improvement initiatives with adherence to regulatory standards.

The position requires strong communication, analytical, and organizational skills, plus experience in claims processing and quality management within the health

Qualifications

• Bachelor’s degree or 2 years’ claims-related experience or 6 years’ claims-related experience in health insurance.
• Strong problem-solving and customer service analysis.
• Familiarity with claims, inquiries, or membership processes and procedures.
• Experience leading meetings or small groups (1 year).
• Experience with quality assessment and process improvement.

Responsibilities

• Complete trending analysis of quality results and triage QOC cases.
• Draft executive summaries and case reports.
• Coordinate case intake and tracking across lines of business.
• Conduct audits and communicate quality program impacts to stakeholders.
• Maintain case documentation and reporting requirements.

Skills

Problem solving

Analytical thinking

Written communication

Verbal communication

Organization

Time management

Research

Critical thinking

Education

Bachelor’s degree

Associate degree

Tools

MHK

Facets

Salesforce Health Cloud

DentaQuest

EPIC

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development.

Job Summary

This position is responsible for completing trending and analysis of quality results; coordinating Quality of Care (QOC) case intake, triage, tracking, and assignment activities; conducting assigned focus audits across various lines of business; drafting executive summary documents and case‑related reports to capture performance results; facilitating meetings and collaboration with internal business partners; drafting solutions to address trends and quality concerns; consulting on specific items impacting quality performance; working with operational areas to evaluate quality programs; maintaining case documentation, medical record requests, and reporting requirements; and communicating the value and impact of quality improvement initiatives while ensuring compliance with established quality standards, regulatory requirements, and performance targets.

Job Requirements

• Bachelor’s degree and 2 years’ experience in claims processing, contract and benefit administration within the health insurance industry OR 6 years’ experience in claims processing, contract and benefit administration within the health insurance industry.
• Experience analyzing and resolving problem claims and customer service issues.
• Knowledge of claims, inquiry OR membership processes and procedures.
• 1 year of experience leading meetings or small groups.
• Experience with quality assessment and process improvement practices.
• Clear and concise written and verbal communication skills.
• Research, analytical, critical thinking and problem‑solving skills.
• Organizational and time management skills.

Preferred Job Requirements

• Experience utilizing MHK, Facets, Salesforce Health Cloud, DentaQuest, EPIC, or similar healthcare systems to research claims, eligibility, clinical information, and services rendered.
• Experience reviewing, triaging, and assigning cases in accordance with established workflows and service‑level expectations.
• Ability to collaborate with internal stakeholders to clarify member complaints, investigate issues, and obtain additional information as needed.
• Experience creating, maintaining, and organizing case documentation in accordance with departmental standards.
• Experience preparing case summaries, supporting documentation, and quality review materials for clinical staff and leadership.
• Experience requesting, tracking, and managing medical records and associated documentation.
• Three (3) or more years of quality review, quality improvement, or healthcare quality management experience.
• Two (2) or more years of experience supporting Quality Management, Grievance and Appeals, or related healthcare operations.
• Knowledge of CMS regulations, NCQA standards, HEDIS, CAHPS, HOS, and healthcare quality improvement methodologies.
• Experience within Medicare, Medicaid, or other government-sponsored healthcare programs preferred.
• Strong organizational, analytical, and documentation skills with the ability to manage multiple cases and deadlines simultaneously.
• Proficiency with Microsoft Office applications, particularly Excel, Word, and Outlook.
• Associate degree in Arts, Science, Healthcare Administration, Business, or a related field preferred.

Pay Transparency Statement

From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees.

Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Base Pay Range

$41,700.00 - $92,800.00 Exact compensation may vary based on skills, experience, and location.

HCSC Employment Statement

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug‑free and smoke‑free workplace. Learn more about HCSC, our commitment to our members and the opportunity you’ll have to improve health care delivery in an open, collaborative environment.

Join our Talent Community

Join our talent community and receive the latest HCSC news, content, and be first in line for new job opportunities.

For more than 80 years, HCSC has been dedicated to expanding access to high‑quality, cost‑effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families.

As an industry leader, HCSC also has been helping to make the health care system work better for all Americans.

To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities.

Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren’t afraid to make innovative contributions.

HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants.

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at 1-866-977-7378 to request reasonable accommodations.