Clinical Quality Management Analyst

Blue Cross and Blue Shield of North Carolina • Durham, CA

1d • $73,698 - $117,917 • Hybrid

About The Position

Evaluates, analyzes and monitors staff or provider performance to achieve excellence in quality. Provides timely, relevant, accurate, and objective feedback to staff, providers, and the management team which includes a plan of action or recommendations when deficiencies are identified. Acts as technical resource and develops learning solutions that engage the learner and produces desired business goals and objectives.

Requirements

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
• 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.

Nice To Haves

• Experience presenting to clinical staff in primary care settings
• Knowledge of HEDIS or healthcare quality measures
• Strong Excel and PowerPoint proficiency
• Ability to translate data into insights (data storytelling)
• Strong presentation and communication skills
• Relationship-building with provider systems
• Flexibility and willingness to travel (25%)

Responsibilities

• Performs quality audits of staff/providers to ensure compliance with departmental, Plans and regulates policies and procedures.
• Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified.
• Monitors and reports on individual and department results to include benchmarking and trending.
• 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.

Benefits

• 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

What This Job Offers

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