Clinical Quality Management Analyst

NC Health Affiliates LLC DBA Blue Cross NC; North Carolina; Hybrid; USD 74,000 - 118,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Parental leave and adoption/surrogacy支

Career development programs andTuition

401k match including an annual company

Job summary

Blue Cross NC is seeking a Clinical Quality Management Analyst to join the Clinical Quality Reporting & Compliance Team. You will evaluate, analyze, and monitor staff or provider performance to achieve quality excellence and provide actionable feedback with recommendations when deficiencies are identified.

You will conduct quality audits to ensure compliance with policies and regulatory requirements, develop learning solutions from audit findings, and report performance trends to inform

Qualifications

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required; previous work experience in UM, CM, Medical Review or quality programs is preferred.
• Bachelor's degree or advanced degree preferred.
• HEDIS clinical measures data extraction is desirable.

Responsibilities

• Conduct quality audits of staff and providers to ensure compliance with departmental objectives, regulatory requirements, policies, and procedures.
• Develop effective learning solutions based on quality audit findings and identified performance gaps.
• Monitor, analyze, and report individual and departmental performance results, including benchmarking and trend analysis.
• Provide guidance with interpretation of clinical aspects of Corporate Medical Policy and other clinical guidelines to assist in making medical decisions.
• Align clinical decision-making processes with regulatory requirements (e.g. DOI/ERISA/NCQA).
• Assist with vendor relationships and/or work closely with vendors; handle ad hoc requests.

Skills

Analytical skills

Communication skills

Problem solving

Quality audits

HEDIS knowledge

Clinical chart reviews

RN/LPN experience

Education

RN license

LPN license

Bachelor's degree preferred

Job description

Job Description

We're hiring a Clinical Quality Management Analyst to join the Clinical Quality Reporting & Compliance Team! Evaluates, analyzes and monitors staff or provider performance to achieve excellence in quality. Provides timely, relevant, accurate, and objective feedback to staff, providers, and the management team which includes a plan of action or recommendations when deficiencies are identified. Acts as technical resource and develops learning solutions that engage the learner and produces desired business goals and objectives.

What You’ll Do

This role is responsible for conducting quality audits of staff and providers to ensure compliance with departmental objectives, regulatory requirements, policies, and procedures. The position also supports the development of effective learning solutions based on quality audit findings and identified performance gaps.

Additionally, it monitors, analyzes, and reports individual and departmental performance results, including benchmarking, trend analysis, and opportunities for continuous improvement. Acts as a day‑to‑day resource for technical assistance and clinical decision making. Provides guidance with interpretation of clinical aspects of Corporate Medical Policy and other clinical guidelines to assist in making medical decisions.

Aligns clinical decision‑making processes with regulatory requirements (e.g. DOI/ERISA/NCQA). Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules and regulations. Works with management team to support decisions on workflow process, quality improvement, goal setting and data‑driven information‑based decision‑making. Provides timely feedback to management on staff/provider performance. Acts to facilitate change efforts and promote department, division and corporate goals.

Assist with Ellkay/CDX changes in data elements. Assists staff with resetting passwords and set up new users for vendor electronic messaging Process IPP Host Plan requests Performs quality audits of member medical records to ensure compliance with HEDIS specifications. Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified. Present findings to vendors/BCNC staff. Monitors and reports on individual and department results to include benchmarking and trending. Provides timely feedback to management on HEDIS performance. May also support ongoing administration of larger and/or more complex programs.

Manage vendor relationships and/or work closely with vendors. Other HEDIS duties or ad hoc requests, as assigned.

What You Bring

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. Bonus Points Knowledge of clinical quality improvement operations, including HEDIS, Medical quality ratings, strongly preferred. Strong analytical, organization, and problem‑solving skills. Strong written, and verbal communication skills and ability to successfully interact with all levels of management. Knowledge of Blue Cross NC or prior healthcare payer experience strongly preferred. HEDIS clinical measures data extraction is desirable. Experience in conducting patient chart reviews to obtain clinical measures is preferred.

What You’ll Get

• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match including an annual company contribution

Where You’ll Work

This role is Remote Flex. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter. Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. *Based on annual corporate goal achievement and individual performance.

$73,698.00 - $117,917.00

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well‑being of North Carolinians. Blue Cross NC is a fully taxed, not‑for‑profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award‑winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

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Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application, hiring process, or have technical issues that prevent you from completing your application please notify HR at [e-mail].

Notice to staffing agencies and search firms

Blue Cross NC does not accept unsolicited resumes from agencies or third parties and is not responsible for fees associated with unsolicited resumes.