Clinical Quality Navigator

Location:

This position is full-time (40-hours/week) Monday-Friday from 8:00am-5:00pm and will be fully remote but the candidate must reside South Carolina.

What You'll Do:

• Abstracts and reviews medical records for 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.
• Participates 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'll Need the Following:

• Required Education: Associates in a job-related field
• Required Work Experience: 4 years-clinical experience to include 2 years of experience in a clinical area providing patient care.
• Required Skills and Abilities: 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.
• Required Software and Other Tools: Microsoft Office, various provider EMRs, and database software.
• Required Licenses and Certificates: 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).

We Prefer That You Have the Following:

• Preferred Education: Bachelor's degree - Nursing
• Preferred Work Experience: Clinical quality experience
• Preferred Work Experience: Previous HEDIS and/or provider education/relation experience.

Our Comprehensive Benefits Package Includes the Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Some states have required notifications. Here's more information.

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.

If you need special assistance or an accommodation while seeking employment, please e-mail mycareer.help@bcbssc.com or call 1-800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.