Job Description

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.

Responsibilities

Your Work

In this role, you will:

• Work with administrative staff on request of medical/clinical records.
• Analyze quality issues from both internal and external sources.
• Make recommendations for level of severity and forward to a medical director (MD).
• Prepare cases for presentation at peer review committees for group review of cases at a higher severity level.
• Prepare education letters and corrective action requests for cases in which it is deemed necessary for the provider to institute a change in their present practices, including cases in which members did not receive the necessary treatment or treatment received was potentially harmful.
• Correspond to providers regarding corrective actions reviewed.
• Collaborate with team members on cases as indicated.

Qualifications

Your Knowledge and Experience

• Requires an Associates Degree in Nursing.
• 5 years of prior relevant experience is required.
• Current California RN license is required.
• 5 years of case review experience required.
• Requires experience working at a health plan (managed care, government payer, or academic).
• Proven experience presenting to medical directors required.
• Excellent analytical and problem-solving skills.
• Requires deep knowledge of job area typically obtained through advanced education combined with experience.
• Viewed as a specialist within the discipline. May have broad knowledge of project management.
• Must have excellent interpersonal, organizational, and communication skills, positive attitude, and a high level of initiative.
• Desired ability to identify problems and work towards problem resolution independently, seeking guidance as needed.
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

About the Team

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.

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