Quality of Care, Clinical Review Nurse

🕒 October 19

🎸 Tennessee – Remote

🎸 Tennessee – Remote

💵 $69.8k - $125.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Health Care Service Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Health Care Service Corporation is an independent licensee of the Blue Cross Blue Shield Association, serving nearly 23 million people across the United States with a wide range of health benefit solutions. The company provides health coverage options for various groups, including employers, individuals, families, as well as Medicare and Medicaid plans. In addition to health insurance, HCSC offers services such as pharmacy solutions, life and dental insurance, and health data technology. With nearly a century of experience, HCSC is dedicated to improving access to quality care, enhancing health outcomes, and reducing costs while maintaining a deep commitment to its members and local communities.

📋 Description

• Conduct reviews and investigations of potential quality of care issues in a timely and efficient manner • Conduct quality improvement and quality management activities in accordance with state and federal regulatory requirements • Evaluate medical records for appropriateness of care • Assess the clinical performance of physicians and other health professionals • Maintain confidentiality of sensitive documents, records, discussions, and information • Keep the QOC Manager updated on activities, identified issues, and actions to address issues • Identify trends, develop recommendations, and present actionable solutions to improve quality outcomes and member experience • Present quality, clinical, operational, or regulatory findings to leadership, providers, committees, and cross-functional stakeholders

🎯 Requirements

• Registered Nurse (RN) with unrestricted license in state of operations • 5 years combined knowledge of healthcare processes • Knowledge of managed care processes • Organizational skills and ability to meet deadlines and manage multiple priorities • Verbal and written communication skills • PC experience including Microsoft Word, Access, and Excel • Strong knowledge of common patient disease processes and usual methods of treating them • Thorough knowledge of medical terminology and commonly used equipment • Ability to evaluate medical records for appropriateness of care • Ability to assess and judge the clinical performance of physicians and other health professionals • Strong analytical, assessment, and problem-solving skills • Effective oral and written communication skills, including explaining complex information and documenting according to standards • Intermediate skills in Word, PowerPoint, Excel, and Outlook; basic ability to enter data into and navigate through a database • Ability to maintain confidentiality of sensitive information • Self-directed and able to work independently • Strong attention to detail and work accuracy • Preferred: presentation and facilitation skills • Preferred: experience conducting clinical reviews, quality of care investigations, root cause analysis, and issue resolution • Preferred: experience developing and delivering training or presentations • Preferred: experience interpreting and communicating complex clinical information and findings • Preferred: experience with Quality of Care, Quality Management, Quality Improvement, Patient Safety, Risk Management, Appeals, Grievances, or related programs • Preferred: knowledge of CMS, NCQA, Medicare, Medicaid, and related regulatory requirements • Sponsorship is not available

🏖️ Benefits

• Curated development plans and professional development • Health and wellness benefits • 401(k) savings plan • Pension plan • Paid time off • Paid parental leave • Disability insurance • Supplemental life insurance • Employee assistance program • Paid holidays • Tuition reimbursement • Annual incentive bonus plan • Other incentives

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