[Hiring] Medicare Risk Adjustment Coder @BlueCross BlueShield of South Carolina

Role Description

We are currently hiring for a Medicare Risk Adjustment Coder to join BlueCross BlueShield of South Carolina. In this role, you will:

• Monitor and collect Medicare Stars data to improve health plan ratings.
• Conduct specific medical record reviews.
• Analyze findings and make recommendations for corrective actions.
• Prepare formal documentation for compliance with applicable standards/regulations.
• Perform Health Plan Employer Data Information Set data collection (HEDIS) and National Committee for Quality Assurance (NCQA) accreditation activities.

Qualifications

• Required Education: Bachelor's in a job-related field.
• Degree Equivalency: 4 years job-related work experience or Associate's and 2 years job-related work experience.
• Required Specialized Training:
  • Professional certification in nursing, pharmacy, medical assistant, or other healthcare training.
  • OR – Certified professional in Healthcare Quality (CPHQ) certificate, Academy for Health Care Management (AHM) certificate, Health Information Management (HIM) certificate, Certified Risk Adjustment Coder (CRC) certificate, or other related certification.
• Required Work Experience:
  • Minimum 2 years of managed care, quality improvement, medical research, or clinical experience.
  • Minimum 2 years working with HEDIS standards, quality measures, and Medicare Advantage (can be concurrent).
  • Must be familiar with clinical terminology and reading paper/electronic medical records.
• Required Skills and Abilities:
  • Ability to work independently with a detailed focus on paper/electronic medical information and other sources to extract needed data for Medicare Star ratings.
  • Ability to understand and follow HEDIS NCQA, HOS, CAHPS, Pharmacy, and Star measure data requirements.
  • Must maintain HIPAA compliance and quality standards.
  • 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.

Requirements

• Preferred Education: Master's degree in healthcare or business-related field or bachelor’s degree and four years of related work experience.
• Preferred Specialized Training:
  • Experience with Medicare Stars, HEDIS, Pharmacy data, NCQA, CAHPS, HOS, Medicare Stars methodology, risk adjustment, medical records, and data analysis.
• Preferred Work Experience:
  • Experience with Retrospective chart review, Prospective gap validation (preferred), and RADV audits or audit preparation (highly preferred).
  • Minimum 4+ years of managed care, quality improvement, medical research, or clinical experience.
  • Minimum 3+ years working with HEDIS standards, quality measures, and Medicare Advantage (can be concurrent).
• Preferred Skills and Abilities:
  • Strong understanding of HCC and RxHCC models, Medicare Advantage risk adjustment methodology, and encounter data and claims submission processes (e.g., EDPS familiarity preferred).
  • Ability to persuade, negotiate, or to influence others.
  • Knowledge of mathematical or statistical concepts.
• Preferred Certifications: CPC, CRC, CCS, or equivalent.
• Preferred Software and Other Tools:
  • Experience with data/analytic platforms such as hybrid tools, HEDIS engines, supplemental data sources, electronic medical records, Tableau, Microsoft Access, and Microsoft Excel.

Benefits

• 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.