Quality & Risk Adjustment Provider Consultant

Blue Cross Blue Shield of Minnesota•Eagan, MN

8d•Hybrid

About The Position

At Blue Cross and Blue Shield of Minnesota, this role supports providers with value-based agreements. The consultant reviews provider-specific data to identify actionable opportunities to improve quality (HEDIS/Stars) and coding accuracy/risk adjustment performance. The role leads face-to-face meetings with provider care-system leaders and develops and drives provider-specific improvement plans. It also serves as an in-house subject matter expert on coding accuracy and quality programs, including HEDIS and Stars. The position is hybrid, with at least two days onsite each week and the remaining workdays remote. Local and non-local travel may be required based on business needs.

Requirements

At least 7 years of related medical coding professional experience.
Bachelor’s degree; in lieu of a degree, an additional two years of relevant experience beyond the stated experience qualification may be accepted.
Required coding certification from AAPC or AHIMA.
Ability to translate complex information into actionable messaging, actively listen to diverse perspectives, and drive alignment across cross-functional priorities.
Ability to analyze complex challenges, evaluate tradeoffs, and collaborate with stakeholders to reach effective, lasting solutions.
Ability to organize work, balance shifting priorities, and manage time across multiple workstreams to meet commitments.
Ability to maintain relationships with internal and external stakeholders, coding experts, and others.
Demonstrated ability to apply critical thinking to coding policy interpretation and implementation.
Ability to travel locally and non-locally as determined by business need.

Nice To Haves

Master’s degree in a related field.
Experience auditing medical records.
Strong knowledge of medical terminology, medical coding, and healthcare regulations.
Certification in Health Care Quality and Manager (CHQM) from a relevant issuer.
Certified Professional in Healthcare Quality (CPHQ) certification from the National Association for Healthcare Quality (NAHQ).
Registered Nurse (RN) license from a state nursing licensing board.

Responsibilities

Identify opportunities for value-based provider groups to improve performance on quality (Stars and HEDIS) and coding accuracy/risk adjustment.
Develop and drive provider-specific action plans to improve quality and coding accuracy performance.
Facilitate regular discussions with provider-group counterparts, including reviewing relevant performance data and progress on action plans.
Consult with providers on best practices to improve performance across quality and coding accuracy measures.
Develop provider-facing materials on performance and improvement opportunities.
Perform additional responsibilities consistent with the scope and level of the role, as assigned.