Clinical Quality Coordinator, Intermediate

Blue Shield of CA; Redding (CA); Hybrid; USD 65.000 - 85.000; Vollzeit

Zusammenfassung

Blue Shield of CA is seeking a Clinical Quality Coordinator to support the Clinical Quality Review team. You will request medical records and provider responses to enable clinical review by CQR staff and assist with PQI reviews to identify improvement opportunities.

The role emphasizes strong communication, familiarity with PC software, and knowledge of managed care concepts. A hybrid virtual work setup applies, with occasional in-office needs for business operations.

Qualifikationen

• 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.

Aufgaben

• Request medical records and responses from providers to facilitate clinical review by CQR staff.
• Support PQI reviews and identify opportunities for improvement.

Kenntnisse

Communication

Verbal & Written

PC proficiency

Healthcare knowledge

Ausbildung

High school diploma or GED + relevant experience

Tools

Microsoft Office

Adobe Acrobat

Jobbeschreibung

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.