Clinical Quality Reviewer - Nurse, Consultant (Behavioral Health)

Blue Shield of CA; Los Angeles (CA); On-site; USD 80,000 - 110,000; Full time

Job summary

An established industry player is seeking a Clinical Quality Review Nurse Trainer/Auditor to join their dynamic team. This role is pivotal in ensuring quality care by reviewing reported issues and supporting operational changes across various lines of business. The ideal candidate will have extensive clinical experience and a strong understanding of regulatory requirements. You will work closely with leadership and subject matter experts to facilitate educational initiatives and improve processes. If you are passionate about quality care and thrive in a fast-paced environment, this opportunity is perfect for you.

Qualifications

• 7+ years of relevant experience in clinical settings.
• Strong knowledge of regulatory and accreditation agencies.
• Ability to work independently in fast-paced environments.

Responsibilities

• Review potential quality of care issues reported by members.
• Support technical and process changes for various lines of business.
• Facilitate educational processes for implementation of changes.

Skills

Verbal/Written Communication

Organizational Skills

PC-based Software Proficiency

Clinical Experience

Knowledge of Regulatory Agencies

Education

Bachelor of Science in Nursing

Current California RN License

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