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.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

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.

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.