Quality and Performance Consultant

Remote TN - Nashville Full time R0055842 At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers. Join HCSC and be part of a purpose-driven company that will invest in your professional development. Job Summary This position is responsible for completing trending and analysis of quality results; coordinating Quality of Care (QOC) case intake, triage, tracking, and assignment activities; conducting assigned focus audits across various lines of business; drafting executive summary documents and case-related reports to capture performance results; facilitating meetings and collaboration with internal business partners; drafting solutions to address trends and quality concerns; consulting on specific items impacting quality performance; working with operational areas to evaluate quality programs; maintaining case documentation, medical record requests, and reporting requirements; and communicating the value and impact of quality improvement initiatives while ensuring compliance with established quality standards, regulatory requirements, and performance targets. Job Requirements Bachelor's degree and 2 years' experience in claims processing, contract and benefit administration within the health insurance industry OR 6 years' experience in claims processing, contract and benefit administration within the health insurance industry. Experience analyzing and resolving problem claims and customer service issues. Knowledge of claims, inquiry OR membership processes and procedures. 1 year of experience leading meetings or small groups. Experience with quality assessment and process improvement practices. Clear and concise written and verbal communication skills. Research, analytical, critical thinking and problem-solving skills. Organizational and time management skills. Preferred Job Requirements Experience utilizing MHK, Facets, Salesforce Health Cloud, DentaQuest, EPIC, or similar healthcare systems to research claims, eligibility, clinical information, and services rendered. Experience reviewing, triaging, and assigning cases in accordance with established workflows and service-level expectations. Ability to collaborate with internal stakeholders to clarify member complaints, investigate issues, and obtain additional information as needed. Experience creating, maintaining, and organizing case documentation in accordance with departmental standards. Experience preparing case summaries, supporting documentation, and quality review materials for clinical staff and leadership. Experience requesting, tracking, and managing medical records and associated documentation. Three (3) or more years of quality review, quality improvement, or healthcare quality management experience. Two (2) or more years of experience supporting Quality Management, Grievance and Appeals, or related healthcare operations. Knowledge of CMS regulations, NCQA standards, HEDIS, CAHPS, HOS, and healthcare quality improvement methodologies. Experience within Medicare, Medicaid, or other government-sponsored healthcare programs preferred. Strong organizational, analytical, and documentation skills with the ability to manage multiple cases and deadlines simultaneously. Proficiency with Microsoft Office applications, particularly Excel, Word, and Outlook. Associate degree in Arts, Science, Healthcare Administration, Business, or a related field preferred. This is a fully remote position, available in the US only, not limited to the posting location. Sponsorship is not available. Pay Transparency Statement At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan. HCSC Employment Statement We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics. Base Pay Range $41,700.00 - $92,800.00 Exact compensation may vary based on skills, experience, and location. For more than 80 years, HCSC has been dedicated to expanding access to high-quality, cost-effective health care and equipping our members with information and tools to make the best health care decisions for themselves and their families. As an industry leader, HCSC also has been helping to make the health care system work better for all Americans. To remain a leader, we offer compelling careers that encourage resourcefulness, strategic thought and empower you to make a difference in the lives of our members and their communities. Today, with the industry at an important crossroad, HCSC is reimagining health care and looking for original thinkers who aren't afraid to make innovative contributions. We are an Equal Opportunity Employment employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Learn more about HCSC, our commitment to our members and the opportunity you'll have to improve health care delivery in an open, collaborative environment. HCSC is committed to diversity in the workplace and to providing equal opportunity to employees and applicants. If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can call us at View phone number on click.appcast.io to request reasonable accommodations. Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to \"candidate home\" to view your job submissions. Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas, Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, and Independent Licensee of the Blue Cross and Blue Shield Association © Copyright 2025 Health Care Service Corporation. All Rights Reserved. #J-18808-Ljbffr