Remote Clinical Quality & Compliance Analyst

Blue Cross and Blue Shield of North Carolina; 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

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