Clinical Quality Management Auditor

Job Description

Evaluates, analyzes and monitors staff or provider performance to achieve excellence in quality. Provides timely, relevant, accurate, and objective feedback to staff, providers, and the management team which includes a plan of action or recommendations when deficiencies are identified. Acts as technical resource and develops learning solutions that engage the learner and produces desired business goals and objectives.

What You'll Do

Primarily responsible for HEDIS overreading to ensure accuracy, consistency, and compliance with quality standards

Support clinical quality leadership on planning activities and large operational activities; works with Clinical Quality leaders to define success metrics and criteria

Analyze reporting and record volumes to ensure program success and collaborate with leadership to modify / redirect activities to meet targets when necessary

Performs quality audits of member medical records to ensure compliance with HEDIS specifications

Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified

Provide timely feedback and recommendations to Clinical Quality Management Consultants based on HEDIS Audits

Drive requirements gathering for medical record abstraction tool enhancements and develop, update, and maintain desktop procedures to ensure accuracy, consistency, and compliance with organizational standards

Manage IPP STARS Care Gap requests in alignment with Blue Cross Blue Shield Association timelines and key performance indicators

Own the endtoend process of initiating, tracking, and resolving support tickets, coordinating tool enhancements, and validating updates through testing in collaboration with vendors and stakeholders

May also support ongoing administration of larger and / or more complex programs

Coach newer HEDIS overreaders and assist with supplemental ad hoc HEDIS or ad hoc requests, as assigned

What You'll Bring

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required
• Must have previous work experience in applicable business area (i.e. HEDIS, Medical Record Review or quality programs)
• Bachelor's degree or advanced degree preferred

Bonus Points

Knowledge of clinical quality improvement operations, including HEDIS, Medical quality ratings, strongly preferred

Strong analytical, organization, and problem-solving skills

Strong written, and verbal communication skills and ability to successfully interact with all levels of management

Knowledge of Blue Cross NC or prior healthcare payer experience strongly preferred

Experience in conducting patient chart reviews to obtain clinical measures is preferred

What You'll Get

The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community

Work-life balance, flexibility, and the autonomy to do great work

Medical, dental, and vision coverage along with numerous health and wellness programs

Parental leave and support plus adoption and surrogacy assistance

Career development programs and tuition reimbursement for continued education

401k match including an annual company contribution

Learn more

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus

$73,698.00 - $117,917.00

Skills