Healthcare compliance [h1.location_city]

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

This position is responsible for completing the activities outlined in the BCBSLA Quality Management Work plan which includes but not limited to working with internal and external representatives to implement, monitor and revise total quality management initiatives, operational procedures and / or performance standards obtain accreditation and achieve strategic goals.

NATURE AND SCOPE

This role does not manage people.

Necessary Contacts : In order to effectively fulfill this position, the incumbent must be in contact with the following : All levels of BCBSLA personnel; physicians and their office personnel; hospitals and allied health provider administration and personnel; medical / surgical equipment suppliers; BCBSLA subscribers; other Blue Plans; URAC; NCQA and other accrediting agencies; LA DOI; BCBS Association; FEP, employer group leaders, licensing boards (LA State Board of Nursing, LA LPN Board, multi-state Medical Boards); certification agencies; contracted vendors (e.g. telephonic messaging vendor, behavioral health utilization management vendor, radiology utilization management vendor, independent review organization, decision support vendor, PBM, health promotion vendors) and other governmental, regulatory or national entities as required (e.g. American Heart Association, LA DHH, American Diabetic Association).

QUALIFICATIONS

Education

Bachelor's in nursing or business related field is required.

In lieu of Bachelor's degree an RN license can be used.

In lieu of Bachelor's degree four years of related experience in healthcare quality can be used.

Work Experience

4 years of professional nursing practice to include two years of experience in healthcare insurance and / or experience in health care quality required.

Prior experience in organizational assessment (audit) and coordinating efforts to gather data and prepare reports to meet requirements (URAC, NCQA and other regulatory / accrediting agencies) required.

Strongly prefer quality management processes; research, interpretation and / or analysis experience.

Experience working with predictive models and Healthcare Quality metrics (e.g. HEDIS) preferred.

Experience can run concurrently.

Skills and Abilities

Strong analytical, research, documentation and report skills and ability to analyze QI data and identify trends and corrective actions required

Excellent oral and written communication, report preparation, and presentation skills to both peer and upper-level management required

Proficient at utilizing computer programs to effectively collect, analyze, present, and communicate data to the various internal and external stakeholders required

Experience with interacting effectively with health care team members preferred

Working knowledge of relevant BCBSLA software systems preferred

Licenses and Certifications

Nursing\RN - Registered Nurse - State Licensure And / Or Compact State Licensure Registered Nurse licensed to practice in the State of Louisiana required

Lean Six Sigma Green Belt Certification or higher level certification preferred

Quality certification (CPHQ, CPC) preferred

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

Coordination with Health Informatics; Population Health; FEP : MTM pharmacists; and other applicable areas with focus on quality improvement (FEP, HEDIS, CAHPS, etc.). Analyzes validity of QM data / reports from a clinical perspective.

Support URAC accreditation activities and Quality improvement activities ensuring on-going accreditation for the Organization.

Performs accurate concurrent and retrospective review, as needed to support performance improvement activities in conjunction with the goals and strategic plan. Assists in performance measurement activities for both providers and the organization (HEDIS, CAHPS and performance measures) at the Plan level, the state level, the BCBS Association level and / or other national initiatives adopted by the Organization to achieve strategic goals.

Utilizes systematic data collection, aggregation, analysis and reporting techniques to achieve concurrent compliance review of identified quality / patient safety metrics.

Assists the Manager and Department Director and collaborates with the Healthcare Innovations team and analysts to compile reports for internal and external consumption. Helps quality improvement (QI) manager to plan, design, implement, and maintain quality improvement program(s).

Assists in internal (BCBSLA employees) and external (membership, community, etc) wellness activities to promote prevention and positive health outcomes of our employees and members. This includes but is not limited to Health Fairs and Gaps in Care programs.

Works with all areas of the company to assist in the implementation and expansion of pay for performance programs, which includes but is not limited to network management, provider quality performance and payment methodologies that support the Plan's corporate goals and maximizes the Plan's competitive position.

Works with Reimbursement and Network Management departments to support quality measurement goals and provider negotiated contracts with the goal of maintaining a high level of provider satisfaction and impact total cost of care.

Maintain access to applicable data portals and support review of performance data to identify quality improvement opportunities.

Serve as representative on organizational committees, work groups, and special projects that impact activities and functions internally and externally assisting in the design of business solutions and achievement of corporate goals. Responsible for Organizational service and clinical committees required to meet regulatory guidelines.

Reporting on opportunities identified and improvement initiatives proposed or in progress. Provide reports comparing progress with national and / or other benchmarks. May require additional research into quality standards and practices.

Pursuit of Lean Six Sigma Green Belt and / or training for Healthcare Quality certification (CPHQ, CPC).

Accountable for complying with all laws and regulations and accreditation standards associated with assigned duties and responsibilities.

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

Perform other job-related duties as assigned, within your scope of responsibilities.

Job duties are performed in a normal and clean office environment with normal noise levels.

Work is predominately done while standing or sitting.

The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY : Insurance