Payment Integrity Nurse – Medicare Advantage

BlueCross BlueShield of South Carolina

Payment Integrity Nurse reviewing Medicare Advantage quality for South Carolina health insurer. Monitoring compliance, conducting medical reviews, coordinating HEDIS collection, and recommending corrective actions.

Posted 8/5/2026full-timeSouth Carolina • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in quality management and compliance within clinical or behavioral health settings, with a strong focus on data analysis, corrective action implementation, and effective communication. Proficient in managing HEDIS data collection and NCQA accreditation activities while ensuring adherence to applicable standards and regulations.

Highest-signal resume keywords

Quality Management ExperienceHEDIS Data CollectionNCQA Accreditation ActivitiesBehavioral Health LicensureAnalytical Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Quality ImprovementData AnalysisMedical Record ReviewCorrective Action ImplementationStatistical Concepts

Soft Skills

Verbal CommunicationWritten CommunicationProblem-SolvingOrganizational SkillsCustomer Service

Tools & Technologies

Microsoft Office

Certifications & Qualifications

Behavioral Health LicensureRN LicensureLPN LicenseRHIA

Industry Keywords

Managed CareCMS GuidanceQuality of CareCompliance Standards

About the role

Key responsibilities & impact

Monitor and maintain compliance through quality improvement activities
Analyze, document, and present quality improvement findings
Recommend corrective actions and improvements
Conduct quality medical record reviews to monitor quality of care and service
Track, trend, and investigate quality concerns and complaints
Coordinate HEDIS data collection
Perform NCQA accreditation activities
Conduct specific medical reviews as necessary
Prepare formal documentation for compliance with applicable standards and regulations
Participate in an on-call rotation covering weekends

Requirements

What you’ll need

Associate degree in a job-related field
4 years of clinical or behavioral health experience, including 2 years of quality management experience
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
Proficiency with Microsoft Office
Active, unrestricted behavioral health licensure from the United States and the state of hire, or active, unrestricted RN licensure from the United States and the state of hire, or an active compact multistate unrestricted RN license under the Nurse Licensure Compact, or RHIA
For DIV 4B only, active unrestricted LPN license in the state of hire
Ability to understand CMS guidance
Ability to persuade, negotiate, or influence others
Knowledge of mathematical or statistical concepts

Benefits

Comp & perks

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
Reasonable accommodations for disabilities, pregnancy-related conditions, and sincerely held religious beliefs
Pay difference coverage for full-time National Guard or Reserve employees called to active duty