Clinical Quality Specialist I

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

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.