Clinical Quality Assurance Auditor - Knoxville

Remote - Location Specific

USA, TN, Chattanooga, Remote

Full time

R-50849

The Clinical Quality Assurance team is looking for an auditor based in the Knoxville, TN region .Our RN auditors perform reviews for network providers to ensure our members are receiving quality care in offices that adhere to our internal quality standards as well as those requirements from regulatory bodies such as Medicare, TennCare and NCQA. While working from home, the auditor will travel to provider offices in the Knoxville region to perform different review types for all lines of business.

You will be a strong candidate for this role if you have the following:

• Registered Nurse (RN) with an active Tennessee license or a license from a Nurse Licensure Compact state.
• 4 years of healthcare experience.
• 1 year of managed care experience or experience with Quality Medical Record Review.
• Experience with HEDIS and/or STARS data collection.
• Strong analytical skills with the ability to identify trends and recommend process improvements.
• We foster a culture where innovation is encouraged, supporting employees with the tools and resources needed to succeed while promoting growth, creativity, and continuous learning.
• Candidate should reside in the Knoxville regional area of TN to facilitate onsite visits to provider offices.

Note:

• Flexibility is required, as provider or leadership needs may occasionally require support outside standard business hours, including after 5:00 p.m

Job 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 for this position.

Job Qualifications

Education

• Bachelor's Degree in Health Care related field or equivalent work experience.

Experience

• 4 years - Health Care experience required.
• 1 year - Managed care experience or experience with Quality Medical Record Review.

Skills\Certifications

• Demonstrated presentation and team facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Excellent oral and written communication skills
• Excellent time and project management skills
• Strong analytical, planning, organizational and research skills

License

• 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.

Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). *The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.

Number of Openings Available

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices (https://www\.bcbst\.com/docs/equal\-employment\-opportunity\.pdf\)

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945. More than that, we're your neighbors and friends – fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.

At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability.

We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST.

We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members.

BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based.

BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense.If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance.