Job Description:

Overview:

The Manager, Clinical Quality Review manages the Blue Shield of California Promise Health Plan Clinical Quality Review (CQR) daily operations and leads the CQR team of nurses and coordinators. CQR investigates and reviews potential quality of care issues (PQIs) arising from member grievances and internal referrals. These reviews can result in identified opportunities for improvement for network providers which help to fulfill Blue Shield's mission to provide care worthy of our family and friends.

Key Responsibilities:

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Delivers effective leadership skills; sets performance goals and provides coaching and feedback to promote a high-performing team; supports a Great Place to Work environment

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Provides subject matter expertise related to management of PQIs and PQI workflows; represents CQR at operational and committee meetings

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Ensures departmental compliance with regulatory, accreditation, legal, contractual and BSC standards and leads the department through audits and surveys

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Tracks inventory, workloads, and operational metrics and takes action when appropriate; produces regular reports

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Evaluates departmental processes and procedures for efficiencies/improvement and leads CQR-related projects

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Contributes to achievement of global business unit goals and objectives

Qualifications:

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Active California RN license required; Bachelor's or higher degree preferred

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3-5+ years hands-on clinical nursing experience across a variety of specialties required

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Quality management, risk management, peer review, or grievance review experience required

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2+ years of experience managing and leading professional staff members

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Advanced knowledge of managed care, health plan product lines (HMO, PPO, Medicare, Medi-Cal, etc.) and accreditation/regulatory agencies and state/federal regulations (DMHC, CMS, DHCS, NCQA, etc.)

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Proficient in typing skills and in use of PC-based software programs including Microsoft Word and Excel

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Excellent communication skills, both written and verbal

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Ability to work in a fast-paced environment with fluid business situations; is flexible and adaptable

Additional Information

- Our Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!

- Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

- Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

- Requisition ID: 200022V

- Posting Date: Sep 25, 2020

- Schedule: Full-time

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