Clinical Quality Assurance Auditor - Knoxville

BlueCross BlueShield of Tennessee • Chattanooga, TN

6d • Hybrid

About The Position

The Clinical Quality Assurance team is looking for an auditor based in the Knoxville, TN region. Our RN auditors perform reviews for network providers to ensure our members are receiving quality care in offices that adhere to our internal quality standards as well as those requirements from regulatory bodies such as Medicare, TennCare and NCQA. While working from home, the auditor will travel to provider offices in the Knoxville region to perform different review types for all lines of business. We foster a culture where innovation is encouraged, supporting employees with the tools and resources needed to succeed while promoting growth, creativity, and continuous learning. Candidate should reside in the Knoxville regional area of TN to facilitate onsite visits to provider offices.

Requirements

• Registered Nurse (RN) with an active Tennessee license or a license from a Nurse Licensure Compact state.
• 4 years of healthcare experience.
• 1 year of managed care experience or experience with Quality Medical Record Review.
• Experience with HEDIS and/or STARS data collection.
• Strong analytical skills with the ability to identify trends and recommend process improvements.
• Bachelor's Degree in Health Care related field or equivalent work experience.
• 4 years - Health Care experience required.
• 1 year - Managed care experience or experience with Quality Medical Record Review.
• Demonstrated presentation and team facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Excellent oral and written communication skills
• Excellent time and project management skills
• Strong analytical, planning, organizational and research skills
• Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
• Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.

Nice To Haves

• Candidate should reside in the Knoxville regional area of TN to facilitate onsite visits to provider offices.

Responsibilities

• Presenting and communicating audit results to appropriate parties; participates in the development of procedures and standards that support and enhance all lines of business' quality of care goals.
• Schedule and perform routine facility, practitioner site, and medical record reviews, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.
• Identifying and evaluating areas of exposure, potential problems and liabilities. Analyze clinical data to improve individual provider compliance with education; provide oversight for regional contract staff and coordinate the effort of retrieval of HEDIS and/or STARS records; complete medical record audits for HEDIS and/or STARS data collection or quality of care reviews as required.
• Providing required documents and consulting support for quality and compliance audits.
• Various immunizations and/or associated medical tests may be required for this position.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level