Clinical Quality Coordinator, Intermediate

Blue Shield of CA; Los Angeles (CA); Hybrid; USD 65,000 - 85,000; Full time

Job summary

Blue Shield of CA is seeking a Clinical Quality Coordinator to support the Clinical Quality Review (CQR) team in investigating PQIs and member grievances. You will coordinate with providers to obtain medical records and facilitate reviews, contributing to process improvements across care quality.

The role supports a hybrid virtual work model with periodic office presence as needed to meet business demands.

Qualifications

• Strong verbal and written communication skills.
• Basic knowledge of PC-based software including Microsoft Suite and Adobe Acrobat.
• Basic knowledge of managed care principles and benefit plans per line of business (HMO, PPO, Medicare) preferred.
• Basic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) preferred.

Responsibilities

• Request medical records and responses from providers to facilitate clinical review by CQR staff.

Skills

Verbal & written communication

Managed care principles

Regulatory knowledge

Education

High school Diploma or GED

Tools

Microsoft Office

Adobe Acrobat

Job description

Your Role

The Clinical Quality Review (CQR) team investigates and reviews potential quality of care issue(s) (PQI) or concerns arising from member grievances and internal referrals. PQI reviews may confirm a quality problem that resulted in, or had the potential for harm, to the member and can lead to identification of provider opportunities for improvement related to practice patterns that are outside the framework of accepted standards. The Clinical Quality Coordinator will report to the Sr. Manager, Clinical Quality Review. In this role you will be primarily responsible for requesting medical records and responses from providers as directed to facilitate clinical review by CQR staff.
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 Knowledge and Experience

• Requires a High school Diploma or GED or 1 year of additional relevant experience in lieu of a diploma
• Requires 3 years of prior relevant experience
• Strong verbal and written communication skills
• Basic knowledge of PC-based software including Microsoft Suite and Adobe Acrobat
• Basic knowledge of managed care principles and benefit plans per line of business (HMO, PPO, Medicare) preferred
• Basic knowledge of regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) preferred

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.