Clinical Quality Coordinator, Intermediate

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

Job summary

Blue Shield of California is seeking a Clinical Quality Coordinator to join the Clinical Quality Review (CQR) team in San Diego. You will help manage medical records requests and support clinical reviews to improve member care.

The role emphasizes collaboration, attention to detail, and effective communication with providers and internal teams; hybrid work with periods in the office as needed.

Qualifications

• Requires a high school diploma or GED or equivalent experience
• Minimum 3 years of relevant experience
• Strong verbal and written communication skills
• Basic knowledge of PC-based software including Microsoft Suite and Adobe Acrobat
• Knowledge of managed care principles and regulatory bodies preferred

Responsibilities

• Request medical records and responses from providers to support clinical review
• Coordinate with CQR staff to prepare cases for review
• Assist in documenting findings and communicating with providers

Skills

Strong verbal and written comms

Attention to detail

Team collaboration

Education

High school diploma or GED or 1 year relevant experience

3 years of prior relevant experience

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.