Quality Navigator
3 weeks ago
Job Summary
We are seeking a highly skilled Quality Navigator to join our team at BlueCross BlueShield of South Carolina. In this role, you will be responsible for abstracting and reviewing medical records for HEDIS (Health Plan Employer Data Information Set) for both prospective and retrospective seasons to ensure compliance with NCQA (National Committee for Quality Assurance) standards and achieve our CMS (Centers for Medicare & Medicaid Services) Star rating.
Key Responsibilities
- Abstract and review medical records for HEDIS for both prospective and retrospective seasons.
- Research and stay up to date on all HEDIS clinical measures and NCQA standards/guidelines.
- Perform quality improvement activities to monitor/maintain quality of care and compliance with applicable standards/regulations.
- Track/trends/investigate quality concerns and complaints.
- Educate network providers on HEDIS clinical measures and coding accuracy.
- Work with providers to collect medical records and provide support to close gaps in care.
- Recommend corrective action or improvement to providers when necessary.
- Develop training materials for provider education.
- Participate in other assigned projects.
- Perform/coordinate HEDIS data collection and NCQA accreditation activities.
- Responsible for continuing education on HEDIS/NCQA measures.
- Provide HEDIS training for new employees.
Requirements
- Associates in a job-related field.
- Four years-clinical experience to include 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.
- 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).
Preferred Qualifications
- Bachelor's degree - Nursing.
- Two years of utilization medical review, quality assurance, and home health experience.
- Two years of health insurance experience.
- Knowledge of the National Committee for Quality Assurance (NCQA).
- Knowledge of Utilization Review Accreditation Commission (URAC).
- Knowledge of the South Carolina Department of Insurance (SCDOI).
- Knowledge of US DOL and Health Insurance.
- Portability/Accountability Act (HIPAA) standards/regulations.
- Excellent organizational and time management skills.
- Knowledge of claims systems.
- Presentation skills.
- Previous HEDIS, provider education, and medical coding experience.
What We Offer
- 401(k) retirement savings plan with company match.
- Subsidized health plans and free vision coverage.
- Life insurance.
- Paid annual leave - the longer you work here, the more you earn.
- Nine paid holidays.
- On-site cafeterias and fitness centers in major locations.
- Wellness programs and healthy lifestyle premium discount.
- Tuition assistance.
- Service recognition.
- Incentive Plan.
- Merit Plan.
- Continuing education funds for additional certifications and certification renewal.
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