Clinical Quality Specialist I at Blue Cross of Idaho in Meridian, Idaho

Job Description:

Blue Cross of Idaho is seeking a Registered Nurse who wants to improve the lives of Idahoans through continuous quality improvement. The Clinical Quality Specialist role is responsible for evaluating Quality of Care concerns, HEDIS improvement efforts, year round data abstraction, training HEDIS nurse abstractors for the annual audit, developing interventions to improve the health of our communities. The Clinical Quality Specialist works daily with a team of clinical and non-clinical staff.



We're looking for Clinical Quality Specialist with:


Experience: 3 years' clinical experience in a health plan and/or health care setting



Education: Associates Degree in Nursing; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)



Licenses/Certifications:



Valid unrestricted Idaho Registered Nursing License



Preferred Qualifications:

• Bachelors in Nursing

What a day would look like:

• Develop training materials and successful training plan for the annual HEDIS audit and HEDIS Nurse Abstractors


• Performs medical record review for select HEDIS measures using technical specifications provided by NCQA to ensure compliance and validity of the abstracted data.


• Serve as a clinical resource to the Quality Management team


• Investigate and prepare Quality of Care concerns for review with clinical team, leadership and in some cases, appropriate committees to determine final leveling of care provided to BCI members


• Review Hospital Acquired Conditions (HAC) report and identify Quality of Care concerns


• Performs root cause analysis when compliance, accreditation or clinical gaps are identified and provides results to leadership.


• Develop and maintain Quality Improvement Plans to support regulatory requirements and development and implementation of corrective action plans when necessary


• Collaborate with the Quality Management team to identify and implement interventions that will improve HEDIS rates and member outcomes


• Ensures effective workflows, maximizes system efficiencies, and monitors quality performance measures; makes recommendations for change as appropriate.


• Review and update policies


• Performs other duties as assigned

As of the date of this posting, a good faith estimate of the current pay range is $71,708 to $100,391. The position is eligible for an annual incentive bonus (variable depending on company and employee performance.


The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, internal equity, geography, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.


We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.


We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.



Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.



We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Apply Now