Clinical Quality Reviewer - Nurse, Senior

Blue Shield of California • Long Beach, CA

2d • Hybrid

About The Position

Your Role

The Clinical Quality Review (CQR) team
is responsible for reviewing potential
quality of care issues (PQIs) reported by a member, a member representative, or
an internal or external partner. The Clinical Quality Reviewer – Nurse, Senior
will report to the Manager, Clinical Quality Review. In this role you will be
responsible for understanding workflows, procedures, and Blue Shield of
California policies to support the technical, cultural and process changes
necessary for the Medicare, Commercial and Medi-Cal lines of businesses
(LOBs). In collaboration with our medical directors, you will follow up / report
results to the appropriate committees for further resolution. You will work with
a clinical team comprised of Registered Nurses (RNs), physicians and
administrative staff to ensure operational compliance with timeliness and
reporting requirements. You will use your clinical expertise to investigate
quality of care issues related to health care concerns.

Our leadership model is about developing great leaders 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.

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun.
Ascendiun is a nonprofit corporate entity that is the parent to a family of
organizations including Blue Shield of California and its subsidiary, Blue
Shield of California Promise Health Plan; Altais, a clinical services company;
and Stellarus, a company designed to scale healthcare solutions. Together, these
organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system
worthy of our family and friends and sustainably affordable. We are transforming
health care in a way that genuinely serves our nonprofit mission by lowering
costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive
and contribute fully to address the needs of the various communities we serve.
We are committed to creating and maintaining a supportive workplace that upholds
our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best
Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360
as a Top Regional Company, and one of the 50 most community-minded companies in
the United States by Points of Light. Here at Blue Shield, we strive to make a
positive change across our industry and communities – join us!  

Our Values: 

Honest. We hold ourselves to the highest ethical and integrity standards. We
build trust by doing what we say we're going to do and by acknowledging and
correcting where we fall short. 
Human. We strive to listen and communicate effectively, showing empathy by
understanding others' perspectives.
Courageous. We stand up for what we believe in and are committed to the hard
work necessary to achieve our ambitious goals. 

Our Workplace Model 

We believe in fostering a workplace environment that balances purposeful
in-person collaboration with flexibility - providing clear expectations while
respecting the diverse needs of our workforce. Our workplace model is designed
around intentional in-person interaction, collaboration,
connection, creativity and flexibility:

For most teams, this means coming into the office two days per week.

Employees living more than 50 miles from an office location, out of state
employees, and employees in certain member-facing roles should work with
their manager to determine in-office time based on business need.

For employees with medical conditions that may impact their ability to work
in-office, we are committed to engaging in an interactive process and
providing reasonable accommodations to ensure their work environment is
conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on
business needs, and requirements are subject to change with periodic reviews.  

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office
Environment. Based in our physical offices and work from home office/deskwork -
Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.
[https://www.blueshieldca.com/physical-job-requirements] 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants
with arrest records and/or conviction records will be considered for employment
in a manner consistent with Federal, State and local laws, including but not
limited to the San Francisco Fair Chance Ordinance. All qualified applicants
will receive consideration for employment without regards to race, color,
religion, sex, national origin, sexual orientation, gender identity, protected
veteran status or disability status and any other classification protected by
Federal, State and local laws.

Responsibilities

• Responsible for understanding workflows, procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs).
• In collaboration with our medical directors, you will follow up / report results to the appropriate committees for further resolution.
• Work with a clinical team comprised of Registered Nurses (RNs), physicians and administrative staff to ensure operational compliance with timeliness and reporting requirements.
• Use your clinical expertise to investigate quality of care issues related to health care concerns.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed