A Career of Your Calling

About Blue Cross and Blue Shield of Minnesota

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

The Impact You Will Have

This position is accountable for performing a wide variety of services related to quality investigations. The associate works as a member of the care management clinical audit team to ensure compliant, effective and efficient investigations 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.

Your Responsibilities

• Perform the initial triage and review of quality issues referred to the Quality Improvement Department, including confirmation of clinical issue needing investigation and categorization for tracking.
• Perform Quality of Care and Quality of Service reviews which includes summarizing medical records and determining if complaint is substantiated. Draft questions for practitioners and clinic staff to answer related to the investigation.
• 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.).
• Draft and implement corrective action plans for providers and practitioners when needed, including tracking and follow-up (case audits, etc.).
• 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.
• Ensure compliance with regulatory and accreditation standards, including HIPAA, NCQA and Department of Labor regulations.
• Ad Hoc collaboration with MDH internal stakeholders during external audits.
• Special projects as assigned.

Required Skills and Experience

• 5+ years of related professional experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
• Registered nurse with current MN license or licensed behavioral health clinician without restrictions or pending restrictions.
• 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.
• High school diploma (or equivalency) and legal authorization to work in the U.S.

Preferred Skills and Experience

• Health Care Administration or Health Plan experience including experience in complaint/grievance processes and requirements.
• Medical Coding education and/or experience.
• CPHQ certification or equivalent healthcare quality or compliance certification.
• Current experience with Electronic Medical Records navigation, specifically EPIC.

Compensation and Benefits:

Pay Range: $77,200.00 - $102,300.00 - $127,400.00 Annual

Pay is based on several factors which vary based on position, including skills, ability, and knowledge the selected individual is bringing to the specific job.

We offer a comprehensive benefits package which may include:

• Medical, dental, and vision insurance
• Life insurance
• 401k
• Paid Time Off (PTO)
• Volunteer Paid Time Off (VPTO)
• And more

To discover more about what we have to offer, please review our benefits page.