Remote Provider Educator & Medicare Risk Adjustment Expert

001 BlueCross and BlueShield of South Carolina; South Carolina; Hybrid; USD 90,000 - 120,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off

Education Assistance

Service Recognition

National discounts

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Independent work

Analytical thinking

Communication skills

HIPAA compliance

Education

Bachelor's degree in a job-related field

Tools

HEDIS data systems

Tableau

Microsoft Excel

NCQA standards

Job description

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.