Clinical Quality Management Analyst

Blue Cross and Blue Shield of North Carolina

3d•$73,698 - $117,917•Remote

About The Position

Blue Cross NC is hiring a Clinical Quality Management Analyst for its Clinical Quality Reporting & Compliance Team. The role evaluates, analyzes, and monitors staff and provider performance to promote quality, providing timely, relevant, accurate, and objective feedback and recommending action when deficiencies are identified. It also serves as a technical resource and develops learning solutions intended to address performance gaps and support business objectives. The analyst conducts quality audits of staff, providers, and member medical records to assess compliance with departmental objectives, regulatory requirements, policies, procedures, and HEDIS specifications. The role monitors, analyzes, benchmarks, trends, and reports individual and departmental performance, identifies opportunities for continuous improvement, and presents findings to vendors and Blue Cross NC staff. It provides day-to-day technical assistance and clinical decision-making guidance, including interpretation of Corporate Medical Policy and clinical guidelines, while aligning decisions with regulatory requirements such as DOI, ERISA, and NCQA. The position collaborates with management on workflow, quality improvement, goal setting, and data-driven decisions; supports change efforts and organizational goals; and works with vendors. Additional duties include assisting with Ellkay/CDX data-element changes, user setup and password resets for vendor electronic messaging, processing IPP Host Plan requests, and supporting administration of larger or more complex programs and other HEDIS requests. This is a Remote Flex role, performed virtually with a few in-office visits each year. Onsite expectations are discussed during the interview process.

Requirements

Registered Nurse (RN) with at least 3 years of clinical experience, or Licensed Practical Nurse (LPN) with at least 5 years of clinical experience.
Previous work experience in an applicable business area, such as utilization management, case management, medical review, or quality programs.

Nice To Haves

Bachelor's degree or advanced degree.
Knowledge of clinical quality improvement operations, including HEDIS and medical quality ratings.
Strong analytical, organizational, and problem-solving skills.
Strong written and verbal communication skills and the ability to interact successfully with all levels of management.
Knowledge of Blue Cross NC or prior healthcare payer experience.
Experience with HEDIS clinical-measures data extraction.
Experience conducting patient chart reviews to obtain clinical measures.

Responsibilities

Conduct quality audits of staff and providers to ensure compliance with departmental objectives, regulatory requirements, policies, and procedures.
Conduct quality audits of member medical records to ensure compliance with HEDIS specifications.
Analyze audit findings and performance gaps and develop effective learning solutions.
Monitor, analyze, benchmark, trend, and report individual and departmental performance results and identify opportunities for continuous improvement.
Provide timely, objective feedback and recommendations to staff, providers, and management, including feedback on HEDIS performance.
Serve as a day-to-day resource for technical assistance and clinical decision-making.
Guide interpretation of Corporate Medical Policy and other clinical guidelines, aligning clinical decisions with requirements such as DOI, ERISA, and NCQA.
Keep current on medical knowledge, care patterns, and regulatory and governmental requirements.
Collaborate with management on workflow, quality improvement, goal setting, and data-driven decision-making.
Facilitate change efforts and promote department, division, and corporate goals.
Assist with Ellkay/CDX changes in data elements.
Help staff reset passwords and set up new users for vendor electronic messaging.
Process IPP Host Plan requests.
Present audit findings to vendors and Blue Cross NC staff.
Manage vendor relationships and/or work closely with vendors.
Support administration of larger or more complex programs and complete other HEDIS duties or ad hoc requests as assigned.