Clinical Quality Assurance Auditor

Job Responsibilities

Presenting and communicating audit results to appropriate parties; participates in the development of procedures and standards that support and enhance all lines of business' quality of care goals.

Schedule and perform routine facility, practitioner site, and medical record reviews, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.

Identifying and evaluating areas of exposure, potential problems and liabilities. Analyze clinical data to improve individual provider compliance with education; provide oversight for regional contract staff and coordinate the effort of retrieval of HEDIS and/or STARS records; complete medical record audits for HEDIS and/or STARS data collection or quality of care reviews as required.

Providing required documents and consulting support for quality and compliance audits.

Various immunizations and/or associated medical tests may be required for this position.

Job QualificationsEducation

Bachelor's Degree in Health Care related field or equivalent work experience.

Experience

4 years - Health Care experience required.

1 year - Managed care experience or experience with Quality Medical Record Review.

SkillsCertifications

Demonstrated presentation and team facilitation skills

Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)

Excellent oral and written communication skills

Excellent time and project management skills

Strong analytical, planning, organizational and research skills

License

Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

We are seeking a skilled and organized RN to join our Clinical Quality Assurance team. This role involves conducting medical record reviews and provider audits to support HEDIS, STARS, quality of care initiatives, accreditation, and compliance requirements. Key responsibilities include analyzing clinical data from electronic medical records, collaborating with providers to enhance quality of care and best practices, improving compliance with HEDIS and accreditation standards, and ensuring our members receive safe and high-quality care.This is a remote position with some travel required for in-office reviews and auditsin the greater Nashville area.If you have experience with audits, medical record reviews, HEDIS, accreditation, and provider education, we encourage you to apply!Number of Openings Available:1Worker Type:EmployeeCompany:BCBST BlueCross BlueShield of Tennessee, Inc.Applying for this job indicates your acknowledgement and understanding of the following statements:BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:BCBST's EEO Policies/Notices (https://www.bcbst.com/docs/equal-employment-opportunity.pdf)BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.Tobacco-Free Hiring StatementTo further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotineand/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.About UsAs Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health for over 65 years. More than that, we're your neighbors and friends – fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based.BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense. If the applicant moves to Chattanooga, TN, they may be eligible for relocation benefits.