RN Clinical Quality Assurance Auditor ( Nashville)

BlueCross BlueShield of Tennessee, Inc.; Chattanooga (TN); On-site; USD 75,000 - 95,000; Full time

Job summary

BlueCross BlueShield of Tennessee, Inc. seeks a Clinical Quality Assurance Auditor to support the Supplemental Data Collection program by reviewing medical records, auditing quality and compliance, and aiding Star measure improvement.

The RN-based role requires a Tennessee license, 4 years of healthcare experience, and knowledge of HEDIS/STARS processes. This remote-first position offers flexible work arrangements and opportunity to impact member care quality nationwide.

Qualifications

• Bachelor's Degree in Health Care related field or equivalent work experience.
• 4 years of health care experience.
• 1 year of managed care experience or experience with Quality Medical Record Review.

Responsibilities

• Present audit results and contribute to procedures and standards.
• Schedule and perform routine reviews of facilities, practitioners, and records.
• Identify and evaluate areas of exposure and liabilities.
• Analyze data to improve provider education and oversee regional staff for HEDIS/STARS data collection.
• Provide required documents and consulting support for audits.
• Immunizations or related medical tests may be required.

Skills

Presentation & facilitation

Microsoft Office

Oral & written communication

Time & project management

Analytical, planning, organizational

Education

Bachelor's degree in health care

Job description

About the Role

The Supplemental Data Collection team at BCBST is seeking a Clinical Quality Assurance Auditor to support the organization in meeting compliance standards, optimize Star measure outcomes, and enhance the overall quality of member care. In this role, you will perform quality, compliance, and inter-reviewer audits to identify opportunities for improvement and ensure consistency, accuracy, and adherence to regulatory requirements. You will review and abstract medical records, analyze clinical data, and collaborate with internal stakeholders to support quality initiatives that positively impact Star ratings and member outcomes. Through effective communication, education, and feedback, you will help drive clinical excellence and promote proper quality of care across the Supplemental Data Collection (SDC) project.

Key Responsibilities

• Presenting and communicating audit results to appropriate parties; participates in the development of procedures and standards that support and enhance all lines of business' quality of care goals.
• Schedule and perform routine facility, practitioner site, and medical record reviews, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.
• Identifying and evaluating areas of exposure, potential problems and liabilities.
• Analyze clinical data to improve individual provider compliance with education; provide oversight for regional contract staff and coordinate the effort of retrieval of HEDIS and/or STARS records; complete medical record audits for HEDIS and/or STARS data collection or quality of care reviews as required.
• Providing required documents and consulting support for quality and compliance audits.
• Various immunizations and/or associated medical tests may be required for this position.

Job Qualifications

• Education: Bachelor's Degree in Health Care related field or equivalent work experience.
• Experience: 4 years - Health Care experience required.
• Experience: 1 year - Managed care experience or experience with Quality Medical Record Review.

Skills and Certifications

• Demonstrated presentation and team facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Excellent oral and written communication skills
• Excellent time and project management skills
• Strong analytical, planning, organizational and research skills

License Requirements

Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Employee Safety & Driver Program

Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). *The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.

Employment Details

• Number of Openings Available: 1
• Worker Type: Employee
• Company: BCBST BlueCross BlueShield of Tennessee, Inc.

EEO Statement

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Company Culture

As Tennessee’s largest health benefit plan company, we’ve been helping Tennesseans find their own unique paths to good health since 1945. More than that, we’re your neighbors and friends – fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow. At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability.

Additional Skills

We’re also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST.

Innovation and AI Use

We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work - guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members.

Remote Policy

BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based. BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense.

Relocation

If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance.