Quality Management Nurse

Blue Cross Blue Shield of Michigan•Detroit, MI

About The Position

Responsible for the completion of assignments for the coordination of the Quality Management Program through problem identification, development and coordination of QM studies, investigation of quality-related member and practitioner inquiries, and plan compliance with state and federal regulations and accrediting bodies. Measures and analyzes results of QI activities, recommends interventions, and conducts follow-up. Collaborates with Care Management, Customer Services, Provider Affairs, and other departments to provide rapid and thorough identification, investigation and resolution of member, practitioner, and provider quality related issues. Works with plan Medical Director on development and revision of Clinical Practice Guidelines. Assists management with the revision of Quality Management policies. Develops, maintains, and enhances reporting methods to identify trends in physician and member behavior. Completes applicable physician summaries (ex. Physician complaint Analysis) as required for re-credentialing. Develops recommendations/tools, as indicated, to improve behavior (for example, Corrective Action Plans). Identifies potential and recurring problems that affect members and providers for the purpose of developing more effective practitioner and member education regarding BCN policies, procedures, and clinical practice guidelines. Creates member and practitioner educational publications related to quality management activities and program information. Serves as Quality Management representative on internal and external committees to aid in the development and evaluation of health promotional and quality management initiatives. Confidentiality is maintained in all aspects of departmental operations involving physicians, providers, members, and external entities. Assists in activities related to commitment to state and federal regulations, purchaser expectations, as well as accreditation bodies such as NCQA and DFIS. Provide support in maintaining NCQA accreditation and compliance with regulatory standards. Responsibilities includes analyzing, summarizing, and preparing accreditation reports, collaborating with stakeholders to collect supporting evidence and perform file review and audits of assigned departments to identify compliance and non-compliance and develop recommendations for corrective actions. Complete Medical record reviews, abstracts, audits, and Facility site visits to ensure compliance with standards set by different agencies like CMS. Enters data into vendor software. Completes provider calls to ensure compliance with access standards set by NCQA. Completes follow up and responds to RFIs related to accreditation activities. Travel may be required.

Requirements

Bachelor’s degree in Nursing, or health-related discipline required.
Registered nurse with a current unrestricted Michigan license required.
Five (5) years broad clinical experience required.
One (1) year Quality Management experience required.
Excellent organizational skills including the ability to handle multiple projects and timelines with minimal supervision required.
Excellent verbal and written communication skills required.
Excellent analytical skills including the ability to provide accurate, objective analysis and reporting of data required.
High level of attention to detail required.
Ability to identify, assess and resolve highly complex problems relating to the delivery of medical services to members and the provider community required.
Self-directed with demonstrated ability to initiate, implement and complete projects effectively required.
Basic knowledge of Microsoft Word required.

Nice To Haves

Basic knowledge of Microsoft Excel and Access, or a similar software program preferred.
Knowledge of statistical analysis and software preferred.
Detailed knowledge of policies and procedures as they pertain to managed care, including the organization of the provider network and the roles and responsibilities of the Provider Services, Medical Management, Care Management, and Customer Services departments preferred.

Responsibilities

Coordinate the Quality Management Program through problem identification, development and coordination of QM studies, investigation of quality-related member and practitioner inquiries, and plan compliance with state and federal regulations and accrediting bodies.
Measure and analyze results of QI activities, recommend interventions, and conduct follow-up.
Collaborate with Care Management, Customer Services, Provider Affairs, and other departments to identify, investigate, and resolve member, practitioner, and provider quality related issues.
Work with the plan Medical Director on the development and revision of Clinical Practice Guidelines.
Assist management with the revision of Quality Management policies.
Develop, maintain, and enhance reporting methods to identify trends in physician and member behavior.
Complete applicable physician summaries (e.g., Physician Complaint Analysis) as required for re-credentialing.
Develop recommendations/tools, as indicated, to improve behavior (e.g., Corrective Action Plans).
Identify potential and recurring problems affecting members and providers to develop more effective practitioner and member education regarding policies, procedures, and clinical practice guidelines.
Create member and practitioner educational publications related to quality management activities and program information.
Serve as Quality Management representative on internal and external committees to aid in the development and evaluation of health promotional and quality management initiatives.
Maintain confidentiality in all aspects of departmental operations involving physicians, providers, members, and external entities.
Assist in activities related to commitment to state and federal regulations, purchaser expectations, and accreditation bodies such as NCQA and DFIS.
Provide support in maintaining NCQA accreditation and compliance with regulatory standards.
Analyze, summarize, and prepare accreditation reports.
Collaborate with stakeholders to collect supporting evidence.
Perform file review and audits of assigned departments to identify compliance and non-compliance and develop recommendations for corrective actions.
Complete Medical record reviews, abstracts, audits, and Facility site visits to ensure compliance with standards set by different agencies like CMS.
Enter data into vendor software.
Complete provider calls to ensure compliance with access standards set by NCQA.
Complete follow-up and respond to RFIs related to accreditation activities.