Job title: Quality Navigator - Healthy Blue Medicaid - Remote - Must Reside in SC Company: BlueCross BlueShield Of South Carolina Job description: Summary Abstracts and reviews medical records for HEDIS (Health Plan Employer Data Information Set) for both prospective and retrospective seasons to ensure that our Company complies with NCQA (National Committee for Quality Assurance) standards and achieves its CMS (Centers for Medicare & Medicaid Services) Star rating. Performs quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations. Educates network providers on HEDIS clinical measures and coding accuracy . Responsible for continuing education on HEDIS/NCQA measures. Performs/coordinates HEDIS data collection, and NCQA accreditation activities. Description Logistics

• This position is full time (40 hours/week) Monday-Friday, 8:00 am 4:30 OR 8:30 am 5:00 pm,
• Position will be fully remote.
• Must have high speed internet (non-satellite) and private area for home office.
• Travel to provider offices to provide education and training will be required.
• Candidate must reside in South Carolina.

What You Will Do:

• Abstracts and reviews medical records for The Healthcare Effectiveness Data and Information Set (HEDIS) for both prospective and retrospective seasons to ensure that our Company complies with NCQA standards and achieves its CMS Star rating. Researches and stays up to date on all HEDIS clinical measures and NCQA standards/guidelines. Performs quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations. Tracks/trends/investigates quality concerns and complaints.
• Educates network providers on HEDIS clinical measures and coding accuracy. Keeps providers up to date on HEDIS clinical measures. Works with providers to collect medical records and provides support to close gaps in care. Recommends corrective action or improvement to providers when necessary. Develops training materials for provider education.
• Participate in other assigned projects. Performs/coordinates HEDIS data collection and NCQA accreditation activities.
• Responsible for continuing education on HEDIS/NCQA measures. Provides HEDIS training for new employees.

To Qualify for This Position, You Will Need:

• Associate's degree- Nursing OR Graduate of Accredited School of Nursing OR Master's degree in Social Work OR Master's in Psychology, or Counseling OR Master's in Health Care Administration.
• Active, unrestricted RN licensure from the United States and in the state of hire OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) OR, active, unrestricted licensure as a pharmacy tech OR, unrestricted licensure as a social worker from the United States and in the state of hire (in Div. 6B) OR, active, unrestricted licensure as a counselor, or psychologist from the United States and in the state of hire.
• Four years of clinical experience including two years of experience in a clinical area providing patient care.
• 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.
• Microsoft Office, various provider EMRs, and database software.
• Excellent verbal and written communication.
• Proficient spelling, grammar, punctuation, and basic business math.
• Customer service, organizational, presentation, problem-solving, and analytical or critical thinking skills.
• Ability to handle confidential or sensitive information with discretion.
• Demonstrate ability to identify the need for and implement corrective actions.
• Strong understanding of managed care.
• Microsoft Office, various provider EMRs, and database software.

What We Prefer

• Previous HEDIS and or provider education experience.
• Medical coding knowledge and/or experience.
• Pediatric and Behavioral Health experience.
• Two years of utilization medical review, quality assurance, or health insurance experience.
• Knowledge of claims