Clinical Quality Coordinator, Intermediate

Blue Shield of California•El Dorado, AR

17h•Hybrid

About The Position

The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Sr. Manager, Clinical Quality Review. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff. Our leadership model is at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. The Clinical Quality Review (CQR) Department investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Clinical Quality Review Manager. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.

Requirements

Requires a high school diploma or GED
Requires basic job knowledge of systems and procedures obtained through prior work experience or education
Typically, requires a minimum of 3 years of prior relevant experience
Strong verbal and written communication skills
Basic knowledge of PC-based software including Microsoft Suite and Adobe Acrobat
Basic knowledge of managed care principles and benefit plans per line of business (HMO, PPO, Medicare) preferred
Basic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) preferred

Responsibilities

Request medical records and/or response requests from providers fax, secure email, or remote electronic medical record system
Validate provider contact information and update department repository accurately
Follow up on medical records and/or response requests via phone or email and implement
Manage incoming medical records/responses accurately and timely
Review medical records upon receipt for content prior to sending for clinical review
Follow up with provider if records are incomplete
Consult with CQR Lead/RN as needed on requests and request status
Prioritize tasks and assignments to meet turnaround time goals
Research provider and member information using internal applications (claims, PCP information, plan type)
Be an active team member and promote a positive work environment
Provide input for continuous process improvement
Enter accurate data into department database to ensure accurate reporting
Work under limited to moderate supervision on routine tasks
Deliver on day-to-day objectives which impact the overall of department goals
May provide guidance and assistance to new or entry level staff
Participate in audit preparation activities