Clinical Quality Management Analyst

Blue Cross and Blue Shield of North Carolina

1d • Remote

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. What You'll Do 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. Assist with maintenance of Web Content Management System (WCMS) and may collaborate with other areas to maintain SOP’s Assists staff with resetting of passwords and set up of new users for vendor electronic messaging What You'll Bring RN with 3 years of clinical experience or LPN with 5 years of clinical experience required 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 What You’ll Get The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community Work-life balance, flexibility, and the autonomy to do great work 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 Learn more Salary Range At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. Based on annual corporate goal achievement and individual performance. $73,698.00 - $117,917.00 Skills Web Content Management System (WCMS) About Us It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives. Authorization to Work in the United States We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview for English or Visión General de E-Verify for Español. Request Accommodations Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at [email protected]. For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming

Requirements

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required
• Must have previous work experience in applicable business area (i.e. UM, CM, Medical Review or quality programs)
• Web Content Management System (WCMS)

Nice To Haves

• Bachelor's degree or advanced degree preferred

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.
• Assist with maintenance of Web Content Management System (WCMS) and may collaborate with other areas to maintain SOP’s
• Assists staff with resetting of passwords and set up of new users for vendor electronic messaging

Benefits

• The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
• Work-life balance, flexibility, and the autonomy to do great work
• 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