Analyst, Accreditation Compliance

at  BlueCross BlueShield of South Carolina

Summary
Responsible for leading accreditation compliance activities to include interpretation of the standards, monitoring of multiple areas’ compliance, providing guidance to management and associates on compliance issues. Provides HEDIS support for multiple departments. Develops special coding plan for HEDIS and Accreditation initiatives. Assists in the oversight and management of Quality Improvement initiatives.
Description
Summary
Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Logistics:
This is a full-time position (40-hours/week) Monday-Friday 8:00am – 5:00pm working on-site at 4101 Percival Rd. Columbia SC, in an office environment. Hybrid will be a possibility after the training period.

What You’ll Do:

• Leads accreditation compliance activities including review and interpretation of the standards, monitoring of multiple areas’ compliance, as well as developing and implementing quality improvement activities to improve compliance. Responsible for maintaining full three-year accreditation status and monitoring National Committee for Quality Assurance (NCQA) and URAC accreditation processes/standards.
• Responsible for providing Health Plan Employee Data and Information Set (HEDIS) support for multiple departments. Monitors HEDIS and informs appropriate management and QI staff of any changes. Also coordinates the preparation of on-site audits conducted by external bodies.
• Develops special coding plan for HEDIS and Accreditation initiatives. Reviews medical records to perform a variety of coding validations for multiple lines of business to monitor the appropriateness of medical care and determine accuracy of billing and payment.
• Researches and monitors CMS rules and regulations around HEDIS, Stars and Risk. Performs compliance analysis and informs management of any changes.
• Conducts/participates in audits of areas, such as member services and utilization management, to ensure compliance with NCQA activities or to assess service issues. Analyzes audit results, makes appropriate recommendations for changes to improve compliance or level of service, works with the other departments to prepare a corrective action plan, prepares formal documentation of the audit, and monitors ongoing corrective action plan to ensure recommendations are being implemented.
• Leads Quality Improvement and Accreditation System (QIAS) activities including specific responsibilities for some of the QIAS as well as oversight and review of all QIAS to ensure compliance with NCQA standards. Conducts analysis of quality improvement activity findings, makes recommendations for corrective actions, prepares formal documentation of activities, presents findings to relevant committees, and monitors corrective action plan to ensure recommended actions are being taken.
• Leads special accreditation/HEDIS projects/activities, as assigned by management, including but not limited to: conduct clinical studies; perform quality of service reviews, including tracking, trending, and profiling; investigate quality of service complaints taking necessary actions to improve clinical and service performance. Coordinates committee meetings and prepares committee minutes.
• Responsible for the reporting of quality of care.

To Qualify for This Position, You’ll Need:

• 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 Work Experience: 5 years of health insurance industry, audit/compliance/investigations, project management, or corporate level related experience.
• Required Skills and Abilities: Ability to effectively communicate both verbal and in writing to all levels of the organization. Knowledge/understanding of medical terminology and medical coding. Excellent analytical or critical thinking and problem solving skills. Ability to make sound decisions and work independently. Ability to exercise confidentiality and discretion. Excellent presentation skills with strong attention to detail.
• Required Software and Tools: Microsoft Office.

We Prefer You Have:

• URAC and/or NCQA Accreditation experience to include interpretation of standards, policy & procedure development and maintenance, as well as project management of survey.
• One year of medical coding experience (may be concurrent with 5 years)
• Ability to Analyze Audit Results
• Ability to Develop HEDIS Coding Plan
• Ability to Lead Special Accreditation Activities
• Ability to Conduct Presentations
• Ability to Prepare Audit Documentation
• Knowledge to Review Medical Records

What We can Do for You:

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
• Wellness program and healthy lifestyle premium discount
• Tuition assistance
• Service recognition
• Employee Assistance
• Discounts to movies, theaters, zoos, theme parks and more

What to Expect Next:
After submitting your application, our recruiting team members will review your resume to ensure your meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements. If the qualifications required proof of semester hours, please attach your transcript to your application.
Management will be conducting interviews with the most qualified candidates, with prioritization give to those candidates who demonstrate the preferred qualifications.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
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more information
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Equal Employment Opportunity Statement
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

• Leads accreditation compliance activities including review and interpretation of the standards, monitoring of multiple areas’ compliance, as well as developing and implementing quality improvement activities to improve compliance. Responsible for maintaining full three-year accreditation status and monitoring National Committee for Quality Assurance (NCQA) and URAC accreditation processes/standards.
• Responsible for providing Health Plan Employee Data and Information Set (HEDIS) support for multiple departments. Monitors HEDIS and informs appropriate management and QI staff of any changes. Also coordinates the preparation of on-site audits conducted by external bodies.
• Develops special coding plan for HEDIS and Accreditation initiatives. Reviews medical records to perform a variety of coding validations for multiple lines of business to monitor the appropriateness of medical care and determine accuracy of billing and payment.
• Researches and monitors CMS rules and regulations around HEDIS, Stars and Risk. Performs compliance analysis and informs management of any changes.
• Conducts/participates in audits of areas, such as member services and utilization management, to ensure compliance with NCQA activities or to assess service issues. Analyzes audit results, makes appropriate recommendations for changes to improve compliance or level of service, works with the other departments to prepare a corrective action plan, prepares formal documentation of the audit, and monitors ongoing corrective action plan to ensure recommendations are being implemented.
• Leads Quality Improvement and Accreditation System (QIAS) activities including specific responsibilities for some of the QIAS as well as oversight and review of all QIAS to ensure compliance with NCQA standards. Conducts analysis of quality improvement activity findings, makes recommendations for corrective actions, prepares formal documentation of activities, presents findings to relevant committees, and monitors corrective action plan to ensure recommended actions are being taken.
• Leads special accreditation/HEDIS projects/activities, as assigned by management, including but not limited to: conduct clinical studies; perform quality of service reviews, including tracking, trending, and profiling; investigate quality of service complaints taking necessary actions to improve clinical and service performance. Coordinates committee meetings and prepares committee minutes.
• Responsible for the reporting of quality of care