Job Description

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.

What You Have

• 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.

Bonus Points

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

Clinical Decision Support (CDS), Clinical Quality Management, Clinical Research, Health Care, Healthcare Operations, Healthcare Policies, Health Information Technology (HIT), Medical Knowledge, Patient Safety, Quality Improvement