Clinical Quality Management Analyst

Job Description

What You'll Do

• This position will primarily focus on HEDIS overreading.
• Review reports and records of activities to ensure progress is being accomplished toward specified program objective and modify or change methodology as required to redirect activities and attain objectives.
• Support clinical quality leadership on planning activities and large operational activities; works with Clinical Quality leaders to define success metrics and criteria.
• Manage and coordinate activities concerned with implementation and carrying out objectives of programs.
• Identify, analyze, and understand target audiences and their specific program needs. 
• Performs quality audits of member medical records to ensure compliance with HEDIS specifications.
• Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified.
• Monitors and reports on individual and department results to include benchmarking and trending.
• Works with management team to support decisions on workflow process, quality improvement, goal setting and data driven information-based decision-making.
• Provides timely feedback to management on HEDIS performance.
• May also support ongoing administration of larger and/or more complex programs.
• Manage vendor relationships and/or work closely with vendors.
• Other HEDIS duties or ad hoc requests, as assigned.

Knowledge and Experience

• Knowledge of clinical quality improvement operations, including HEDIS, Medical quality ratings, strongly preferred.
• Strong analytical, organization, and problem-solving skills.
• Strong written, and verbal communication skills and ability to successfully interact with all levels of management.
• Knowledge of Blue Cross NC or prior healthcare payer experience strongly preferred.
• HEDIS clinical measures data extraction is desirable.
• Experience in conducting patient chart reviews to obtain clinical measures is preferred.

What You'll Bring (Hiring Requirements)

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required.
• Must have previous work experience in applicable business area (i.e. HEDIS, Medical Review or quality programs).
• Bachelor's degree or advanced degree preferred.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.