BlueCross BlueShield of Tennessee · 5 hours ago
Clinical Quality Assurance Auditor
United States
Full-time
Remote
Mid Level
4+ years expBlueCross BlueShield of Tennessee is seeking a Clinical Quality Assurance Auditor to join their Senior Care team. In this role, you will help improve care quality and drive stronger outcomes for senior members by auditing provider documentation, analyzing clinical data, and ensuring compliance with regulatory standards.
Health CareMedical
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
Qualification
Required
Bachelor's Degree in Health Care related field or equivalent work experience
4 years - Health Care experience required
1 year - Managed care experience or experience with Quality Medical Record Review
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
Strong decision‑making and critical‑thinking skills
High attention to detail and accuracy
Excellent written and verbal communication skills
Demonstrated presentation and team facilitation skills
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Excellent time and project management skills
Strong analytical, planning, organizational and research skills
Preferred
Prior HEDIS or quality‑reporting experience
Company
BlueCross BlueShield of Tennessee
As Tennessee's largest health plan, we've been helping Tennesseans find their own unique paths to good health for more than 70 years.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Casey Dungan
President and Chief Executive Officer - BlueCare
Melissa Scissom
COO, Cover Tenn
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