Clinical Quality Reviewer - Nurse, Consultant (Behavioral Health)

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

Job summary

Join a forward-thinking healthcare organization as a Clinical Quality Review Nurse Trainer/Auditor. In this pivotal role, you will leverage your extensive nursing experience to enhance quality of care across various lines of business. Collaborating with leadership and subject matter experts, you'll provide essential training and support, ensuring compliance with regulatory standards while fostering a culture of excellence. This position offers a dynamic work environment where your contributions will directly impact patient care and operational efficiency. If you're passionate about making a difference in healthcare, this is the opportunity for you.

Qualifications

• 7+ years of relevant nursing experience required.
• Current California RN license is mandatory.

Responsibilities

• Support nurses and coordinators with quality of care issues.
• Facilitate educational and change management processes.

Skills

Verbal/Written Communication

Organizational Skills

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Microsoft Outlook

Clinical Experience

Knowledge of Regulatory Agencies

Education

Bachelor of Science in Nursing

Tools

PC-based Software

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