Job Description
Job Description Your Role The Clinical Quality team is responsible for reviewing and abstracting medical records to capture data and to ensure accuracy and completeness. The Clinical Quality Reviewer - Nurse Senior will report to the Manager, Clinical Quality Analytics. In this role you will be reviewing medical records to support HEDIS and other regulatory audits. This role will require the ability to train others on HEDIS specifications and guidelines. This role will research and create medical record review reports and interpret findings.
Responsibilities Your Work In this role, you will:
- Analyze quality issues from both internal and external sources.
- Determinate case level of severity and escalate issues to a medical advisor (MD) and/or credentialing committee for final determination.
- Prepare cases for presentation at physician committees for group review of cases at a higher severity.
- Prepare corrective action requests for cases in which it is deemed necessary for the provider to institute a change in their present practices including cases where member did not receive necessary treatment or treatment received was potentially harmful.
- Correspond with physicians regarding corrective actions reviewed while maintaining HIPPA Standards
- Reviewing medical records and documents to abstract clinical data for HEDIS and other audits while identifying opportunities for process improvements
- Meeting daily abstraction and overread goals while maintaining a high accuracy percentage
- Training and advising healthcare professionals and contingent staff on HEDIS and other audit regulatory compliance
- Support collection of medical record and reports
Qualifications Your Knowledge and Experience - Bachelor of Science in Nursing or advanced degree preferred
- Current California RN license is required.
- Requires at least 5 years of prior relevant experience.
- Required 3 years of previous HEDIS Medical record review experience
- Excellent analytical and problem-solving skills.
- Requires deep knowledge of job area typically obtained through advanced education combined with experience.
- Viewed as a specialist within discipline. May have broad knowledge of project management.
- Required experience in Excel and HEDIS audits
- Desired experience and knowledge of medical record systems and processes
- Desired knowledge and familiarity in EMR software such as Epic, EClinical Works, Allscripts, NextGen, etc.
- Desired knowledge of ICD-10, CPT, and other modifier codes
About the Team About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values: - Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model: At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
- Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
- On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
Job Tags
Full time, Part time, Work at office, Local area, Remote work, Work from home, Home office, 1 day per week,