Clinical Quality Reviewer - Nurse, Consultant (Behavioral Health)

Blue Shield of CA; California, Cameron Park (MO, CA); On-site; USD 70,000 - 100,000; Full time

Job summary

An innovative healthcare organization is seeking a Clinical Quality Review Nurse Trainer/Auditor to enhance quality of care across multiple lines of business. This dynamic role involves collaborating with leadership and subject matter experts to implement educational and change management processes. The ideal candidate will possess a strong clinical background, excellent communication skills, and the ability to navigate regulatory environments. Join a forward-thinking team dedicated to providing superior care and support in a fast-paced setting where your expertise will make a significant impact.

Qualifications

• 7+ years of relevant experience in clinical settings.
• Current California RN license required.

Responsibilities

• Support technical and process changes for Medicare and Medi-Cal.
• Facilitate educational processes for implementation of changes.

Skills

Verbal/Written Communication

Organizational Skills

Clinical Experience

Regulatory Knowledge

PC Software Proficiency

Education

Bachelors of Science in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Microsoft Outlook

Job description

Your Role

The Clinical Quality Review (CQR) team is responsible for reviewing potential quality of care issues (PQIs) reported by a member, a member representative, or an internal partner. The Clinical Quality Review (CQR) Nurse Trainer/Auditor will report to the Senior Manager, Clinical Quality Review. In this role you will be responsible for understanding workflows, operational procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). This position provides frontline support for nurses and coordinators and works in collaboration with leadership. The CQR Nurse Trainer/Auditor works closely with subject matter experts for each line of business (LOB) to facilitate educational and change management processes for implementation of changes as needed.

Your Knowledge and Experience

• Requires a Bachelors of Science in Nursing or equivalent experience


• Requires at least 7 years of prior relevant experience


• Requires a current California RN license


• Requires 3-5 plus years hands-on clinical experience across a variety of specialties and settings


• Strong verbal/written communication and organizational skills


• Proficient in use of PC-based software programs including Microsoft Word, Excel, PowerPoint, and Outlook with strong typing skills required


• Ability to work independently in a fast-paced and fluid work environment


• Experience with, or strong working knowledge of, regulatory and accreditation agencies (DMHC, DHCS, CMS, NCQA) and managed care for various lines of business (HMO, PPO, Medicare, Medi-Cal, Cal Medi-Connect)


• Consistent demonstration of knowledge, skills, abilities, and behaviors needed to provide superior and culturally sensitive service to team members, and contracted providers