Provider Clinical Quality Specialist

Blue Cross & Blue Shield of Mississippi•Flowood, MS

4d•Onsite

About The Position

At Blue Cross & Blue Shield of Mississippi, we are creating a strong, supportive community which encourages every Mississippian to live their healthiest life. This mission requires a talented and motivated team with diverse sets of skills and experiences, aligned with the commitment of a healthy Mississippi. We are seeking a Provider Clinical Quality Specialist to develop, implement, and maintain quality programs as it relates to Women’s Health and Maternal Quality Care. As the driving force of this initiative, this Clinician partners with network providers and hospitals, as well as internal stakeholders to evaluate, structure, implement, and enhance the components of a best practice model value-based program to establish guidelines which support optimal patient care experiences and health outcomes. Once established, this role ensures shared responsibility for outcomes and practices are consistently reviewed for agreement and alignment with best practice measurements and patient care success rates. This clinical role in a professional setting provides the opportunity to make a state-wide impact on Maternal Care and Women’s Health. A typical day is working with an internal team to analyze data and meet with providers and quality staff to translate complex data into actionable clinical improvements by influencing provider/staff behavior.

Requirements

Bachelor’s degree in nursing and R.N. licensure that is unrestricted in the state of Mississippi, or advanced practice degree.
Three years’ healthcare clinical experience as a nurse or nurse practitioner.
Skilled in implementing focused activities for monitoring/improving health-related outcomes
Presentation presence that is professionally engaging as well as the ability to explain technical information to a non-technical audience.
Intermediate proficiency utilizing software in the Microsoft Office Suite, specifically Word and Excel
Ability to work a flexible schedule when required with limited or frequent travel.

Nice To Haves

Master’s degree in nursing or healthcare administration
Comprehensive understanding of Women’s Health and Obstetrics Care Best Practices.
Intermediate proficiency with Microsoft Access and Visio
Practical knowledge of Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases, Tenth Revision (ICD10), Uniform Billing (UB) Revenue and National Drug Code (NDC) coding.
Skilled in data interpretation and statistical analysis for healthcare related trends.
Background in the development of provider/hospital quality management programs.
Solid understanding of value-based programs such as Bundled Payments for Care Improvement (BPCI) and Physician Quality Reporting System (PQRS).
Working knowledge of accreditation programs such as Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and National Committee for Quality Assurance (NCQA).

Responsibilities

Research, analysis, and documents clinical best practice guidelines and related quality measures which align with evidence-based best practice guidelines and value-based reimbursement models.
Documents technical specifications related to specific quality measures to be used internally for data reporting and externally for transparency with Network Providers.
Presents actionable data to network providers, sharing current quality performance scores against expectations and identifying opportunities for improvement.
Maintains knowledge of relevant provider quality initiatives and value-based reimbursement models such as Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Bundled Payment for Care Improvement (BPCI) and Physician Quality Reporting System (PQRS).