Quality and Performance Consultant

Medicare; Nashville (TN); Remote; USD 48,000 - 86,000; Full time

Job summary

HCSC is seeking a Quality Analyst to perform trending and analysis of quality results, coordinate QOC case intake, triage, tracking, and assignment activities, and conduct focused audits across multiple lines of business.

The role involves drafting executive summaries and case-related reports, facilitating meetings with internal partners, and proposing solutions to address trends and quality concerns while ensuring compliance with quality standards and regulatory requirements.

Qualifications

• Bachelor’s degree or 2+ years in claims processing within health insurance.
• Alternatively, 6+ years in claims processing within health insurance.
• Experience analyzing and resolving problem claims and customer service issues.
• Strong written and verbal communication skills.
• Organizational and time management skills.
• Knowledge of claims, inquiry or membership processes.

Responsibilities

• Trend and analyze quality results to identify patterns.
• Coordinate Quality of Care (QOC) case intake, triage, and assignment.
• Conduct focus audits across lines of business.
• Draft executive summaries and case reports on performance results.
• Facilitate meetings with internal stakeholders.
• Develop solutions to address trends and quality concerns.
• Maintain case documentation and reporting requirements.
• Support quality programs and ensure regulatory compliance.

Skills

Claims processing

Problem solving

Analytical thinking

Communication skills

Organizational skills

Time management

Education

Bachelor’s degree

Associate degree (Arts, Science, Healthcare Administration, Business) preferred

Tools

MHK

Facets

Salesforce Health Cloud

DentaQuest

EPIC

Microsoft Office

Excel

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.

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.

This is a fully remote position, available in the US only, not limited to the posting location.

Sponsorship is not available.

Compensation: $47,500.00 - $86,000.00

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.

To learn more about available benefits, please click https://careers.hcsc.com/totalrewards