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Health Plan Clinical Quality Coordinator Job

Date: Mar 4, 2019

Location: Eagan, Minnesota, US, 55122

Company: Blue Cross and Blue Shield of Minnesota

For more than 80 years, Blue Cross and Blue Shield of Minnesota has been passionate about improving health. We provide quality, cost-effective health plans and innovative programs that make a healthy difference in people’s lives. Blue Cross is the largest health plan based in Minnesota, covering nearly 3 million members in the state and across the country. We strive to help all Minnesotans overcome the barriers to good health.



 



We offer our employees a comprehensive benefits, compensation and total rewards package to keep you and your family healthy and to secure your financial future. Our Employee Resource Groups help us advance health equity while promoting a diverse and inclusive work environment. Join us and make a healthy difference in people’s lives through the work you do every day. Together, we'll make Minnesota a better place to live — and a healthier one.


Description Summary

This position is accountable for performing the overall management, monitoring, and delivery of a wide variety of services related to quality investigations. The Coordinator works as a member of the accreditation team to ensure compliant, effective and efficient investigation of quality issues impacting the health and service of Blue Cross and Blue Plus members. This work contributes directly to adherence with regulatory and accreditation requirements including the organizations Quality Improvement Program. This position collaborates with multiple stakeholders at many levels across the company, as well as with external entities, providing coordination and support as required.


Accountabilities


  1. Perform the initial triage and review of quality issues referred to the Quality Improvement Department, including: confirmation of clinical issue needing investigation; categorization for tracking, trending and reporting ability; requesting medical records and other documentation from practitioners and clinic locations; drafting questions for practitioners and clinic staff to answer related to the investigation.

  2. Organize and manage documentation, policies and procedures, job aids, manuals, file system, reporting and outcome measurement related to the quality investigations, including connections with other departments (contracting, credentialing, medical management, etc.).

  3. Prepare clinical quality investigation files for review by clinical staff within the organization, including nurses, medical directors, external peer reviewers, credentialing committee and the applicable Board of Medical Practice. Draft and implement corrective action plans for providers and practitioners when needed, including tracking and follow-up (case audits, etc.).

  4. Maintain and monitor timeliness for quality investigations, including requests of external entities and internal staff reviews.

  5. Coordinate and perform special projects and assignments within specific time frames, which may include annotation of accreditation evidence to prepare for submission to external accreditation agency or state regulators; including augmentation of Accreditation Coordinator duties as needed.

  6. Develop and manage regular standardized reporting to meet regulatory, accreditation, contractual and other requirements; including spreadsheets, databases and other systems as needed; including summarizing cases and analysis; creating presentations and facilitating Director-Level Quality Committee reports.

  7. Ensure compliance with regulatory and accreditation standards, including HIPAA, NCQA and Department of Labor regulations.


Requirements


  • Degree in nursing or other clinical field and 5 years of related work experience, or 9 years combined education and experience in lieu of a degree. Related experience may be in roles involving coordination, organizing documents and/or information, tracking data or processes, but must have a clinical component including work in a clinical setting.

  • Detail orientation, with the ability to compare clinical practices against current standard of care / best practices, evaluating compliance, recommending improvement strategies, and producing accurate documentation.

  • Demonstrated ability to work independently and make decisions as needed, must possess a proven track record of achievement.

  • Organized and able to manage several priorities against challenging deadlines.

  • Ability to develop strong cross-functional and collaborative relationships with internal and external partners, including the ability to work with a wide variety of people and personalities. Must project a strong professional image when representing Blue Cross externally.

  • Must be self-motivated, able to take initiative, and work independently with minimal oversight to meet timelines, including strong follow-through skills and a solutions-oriented attitude.

  • Experience in using Microsoft Excel, Word and Access as well as demonstrated ability to learn/adapt to computer-based tracking tools.

  • Knowledge of medical terminology.


Preferred Requirements


  • Health Care Administration or Health Plan experience including experience in complaint/grievance processes and requirements.

  • Active License to practice nursing in the State of Minnesota.

  • Medical Coding education and/or experience CPHQ certification or equivalent healthcare quality or compliance certification.

  • Current experience with Electronic Medical Records navigation, specifically EPIC.


FLSA Status

Exempt


Blue Cross Blue Shield of Minnesota is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Make a difference



Thank you for your interest in Blue Cross. Be part of a company that lets you be you — and make a healthy difference in people’s lives every day



Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.



Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association


Nearest Major Market: Minneapolis

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