Remote Clinical Quality & Compliance Analyst

Blue Cross and Blue Shield of North Carolina; South Carolina; Remote; USD 74,000 - 118,000; Full time

Benefits offered by this job

Remote work options

Medical, dental, and vision coverage

401k with company match

Paid time off (PTO)

Parental leave and support

Tuition reimbursement

Job summary

Blue Cross NC is seeking a Clinical Quality Management Analyst to evaluate and monitor staff and provider performance, ensuring quality and regulatory compliance. The role includes developing learning solutions and offering actionable feedback to drive improvements.

Responsibilities include conducting quality audits, analyzing results, benchmarking trends, and guiding management decisions. Remote Flex with occasional in-office visits; strong clinical background preferred.

Qualifications

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• Bachelor's degree or advanced degree preferred.
• Experience in UM, CM, Medical Review or quality programs.

Responsibilities

• Conduct quality audits of staff and providers to ensure compliance with departmental objectives, regulatory requirements, policies and procedures.
• Develop learning solutions based on quality audit findings and identified performance gaps.
• Monitor, analyze and report performance results, including benchmarking and trend analysis.
• Provide clinical interpretation guidance to support decisions and align with regulatory requirements (DOI/ERISA/NCQA).
• Assist with Ellkay/CDX changes in data elements and set up for new users; manage vendor relationships.

Skills

Quality audits

HEDIS knowledge

Data analysis

Regulatory compliance

Education

Bachelor's degree

Advanced degree preferred

Tools

Ellkay/CDX

Job description

Blue Cross NC is seeking a Clinical Quality Management Analyst to evaluate and monitor staff and provider performance, ensuring quality and regulatory compliance. The role includes developing learning solutions and offering actionable feedback to drive improvements.

Responsibilities include conducting quality audits, analyzing results, benchmarking trends, and guiding management decisions. Remote Flex with occasional in-office visits; strong clinical background preferred.