Clinical Quality Assurance Auditor

BlueCross BlueShield of Tennessee • Chattanooga, TN

11d

About The Position

Join the Senior Care team as a Clinical Quality Assurance Auditor ! In this role you will help improve care quality and drive stronger outcomes for our senior members by: Auditing provider documentation and supporting HEDIS quality initiatives Analyzing clinical data to identify gaps and performance opportunities Partnering with provider offices to enhance Stars performance Ensuring compliance with regulatory and organizational standards Supporting provider outreach to strengthen quality measures across the network In addition to having an RN license and meeting the job requirements of the role, our ideal candidate has: Strong decision‑making and critical‑thinking skills High attention to detail and accuracy Excellent written and verbal communication skills Prior HEDIS or quality‑reporting experience Job 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.

Requirements

• 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

• Strong decision‑making and critical‑thinking skills
• High attention to detail and accuracy
• Excellent written and verbal communication skills
• Prior HEDIS or quality‑reporting experience

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.

What This Job Offers

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