Clinical Quality & HEDIS Analyst (Remote)

Blue Cross and Blue Shield of North Carolina; Colorado; Remote; USD 74,000 - 118,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Parental leave and adoption/surrogacy‑

Tuition reimbursement

401k match

Job summary

Blue Cross NC is seeking a Clinical Quality Management Analyst to join the Clinical Quality Reporting & Compliance Team. This role evaluates and monitors staff or provider performance to drive quality improvements and provides actionable feedback.

You will develop learning solutions, support clinical decision making with policy interpretations, and monitor performance including benchmarking and trend analysis.

Qualifications

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required.
• Must have previous work experience in applicable business area (i.e. UM, CM, Medical Review or quality programs).
• Bachelor's degree or advanced degree preferred.

Responsibilities

• Conduct quality audits of staff and providers to ensure compliance with objectives, regulations, and policies.
• Provide guidance on clinical decision making and interpret clinical guidelines to support decisions.
• Monitor, analyze, and report performance results including benchmarking and trend analysis.
• Assist with Ellkay/CDX changes in data elements.
• Assist staff with resetting passwords and setting up new vendor users.
• Process IPP Host Plan requests and perform quality audits of member medical records for HEDIS compliance.
• Design learning solutions based on audit results and present findings to vendors/BCNC staff.
• Monitor and report on department results including benchmarking and trends.
• Support vendor relationships and other ad hoc duties as assigned.

Skills

Analytical skills

Organizational skills

Problem-solving

Communication skills

Education

Bachelor's degree

Advanced degree preferred

Job description

Blue Cross NC is seeking a Clinical Quality Management Analyst to join the Clinical Quality Reporting & Compliance Team. This role evaluates and monitors staff or provider performance to drive quality improvements and provides actionable feedback.

You will develop learning solutions, support clinical decision making with policy interpretations, and monitor performance including benchmarking and trend analysis.