We are currently hiring for a Medicare Risk Adjustment Coder to join BlueCross BlueShield of South Carolina. This role monitors and collects Medicare Stars data to improve health plan ratings, conducts specific medical record reviews, analyzes findings, recommends corrective actions, prepares compliance documentation, and performs HEDIS and NCQA accreditation activities.
Location
This position is full-time (40 hours/week) Monday-Friday with an 8‑hour shift between 7:00 am-9:00 pm and is fully remote. The candidate may be required to come on‑site for occasional training, meetings, or other business needs.
What You'll Do
Coordinate HEDIS and Star measure data collection using analytic resources, paper records, electronic medical charts and other authorized resources.
Conduct data entry and review of Star measure data in accordance with NCQA and CMS technical specifications.
Maintain oversight of external data sources and vendors.
Use available Stars data to identify opportunities for improvement and support the development of Stars program initiatives.
To Qualify for This Position, You'll Need the Following:
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 CPHQ, AHM, HIM, CRC or other related certification.
Required Work Experience: Minimum 2 years in 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 read paper/electronic medical records.
Required Skills and Abilities: Work independently with detailed focus on paper/electronic medical information to extract data for Medicare Star ratings; understand and follow HEDIS, NCQA, HOS, CAHPS, Pharmacy and Star measure data requirements; maintain HIPAA compliance and quality standards; excellent communication, customer service, organization, presentation, problem‑solving and analytical skills; proficient spelling, grammar, punctuation, basic business math; handle confidential information with discretion; identify and implement corrective actions; strong understanding of managed care.
We Prefer That You Have the Following:
Preferred Education: Master’s degree in healthcare or business-related field or bachelor’s degree and four years 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, and RADV audits or audit preparation.
Minimum 4+ years in managed care, quality improvement, medical research or clinical experience; minimum 3+ years 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, encounter data and claims submission processes (e.g., EDPS familiarity).
Ability to persuade, negotiate, or 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.
Our Comprehensive Benefits Package Includes the Following:
Subsidized health plans, dental and vision coverage
401(k) 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
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and its subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote 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. As a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. We are committed to providing equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We provide reasonable accommodations to individuals with disabilities, pregnant individuals and others as required by law.
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