Clinical Quality Management Analyst

Job Description

What You'll Do

• This role is responsible for conducting quality audits of staff and providers to ensure compliance with departmental objectives, regulatory requirements, policies, and procedures. The position also supports the development of effective learning solutions based on quality audit findings and identified performance gaps. Additionally, it monitors, analyzes, and reports individual and departmental performance results, including benchmarking, trend analysis, and opportunities for continuous improvement.
• Acts as a day-to-day resource for technical assistance and clinical decision making. Provides guidance with interpretation of clinical aspects of Corporate Medical Policy and other clinical guidelines to assist in making medical decisions. Aligns clinical decision-making processes with regulatory requirements (e.g. DOI/ERISA/NCQA). Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules and regulations.
• Works with management team to support decisions on workflow process, quality improvement, goal setting and data driven information-based decision-making. Provides timely feedback to management on staff/provider performance. Acts to facilitate change efforts and promote department, division and corporate goals.
• Assist with Ellkay/CDX changes in data elements.
• Assists staff with resetting passwords and set up new users for vendor electronic messaging
• Process IPP Host Plan requests
• 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. Present findings to vendors/BCNC staff.
• Monitors and reports on individual and department results to include benchmarking and trending.
• Provides timely feedback to management on HEDIS performance.
• May also support ongoing administration of larger and/or more complex programs.
• Manage vendor relationships and/or work closely with vendors.
• Other HEDIS duties or ad hoc requests, as assigned.

What You 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. UM, CM, Medical 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.
• HEDIS clinical measures data extraction is desirable.
• 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

Where You'll Work

This role is Remote Flex. In a Remote Flex role, you'll work virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

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*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

Skills

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