Job Description

Support the development and maintenance of a high performing quality provider network by engaging with Accountable Care Organizations (ACOs) and independent primary care providers to promote quality improvement for NCQA Healthcare Effectiveness and Data Information Set (HEDIS) measures, MA Stars and developing improvement plans when needed. Implement and manage all Quality Management activities for assigned providers. Work closely with relevant Blue Cross NC stakeholders to educate providers regarding quality management and preventive health initiatives and programs.

What You'll Do

• Some onsite clinical practice visits required (East: Wilmington area and West: Asheville area).

• Maintain a collaborative working relationship with assigned providers to streamline processes related to Healthcare Effectiveness Data and Information Set (HEDIS) measures to maximize outcomes of NCQA accreditation, Medicare Stars, HEDIS Measure performance and improve provider satisfaction.

• Provides guidance with interpretation of clinical aspects of Corporate Medical Policy and HEDIS Measures, develops, and implements quality improvement plans based on departmental goals. Aligns clinical decision-making processes with regulatory requirements (e.g., DOI/ERISA/NCQA). Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules, and regulations.

• Provides education and supports implementation of Blue Cross NC quality-based programs ensuring care cap closure (including HEDIS medical record abstraction) to improve member outcomes. Programs include but not limited to: Blue Premier and Medicare Advantage Quality Incentive Program (MAQIP).

• Utilize data analysis and visualization tools to create presentations, providing relevant and actionable feedback to providers in monthly quality workstream meetings in collaboration with internal quality teams and external stakeholders.

• Assists in the evaluation, development, and integration of Quality Management programs in support of new corporate initiatives. Participate in change efforts and promotes department, division, and corporate goals.

• Collects, organizes, and disseminates “best practices” information regarding providers operating within Value Based Programs. Supports the development of continuous quality improvement activities.

• Provides local presence for Quality Management (QM) related activities.

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What You'll Bring (Hiring Requirements)

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience required.

• Must have previous work experience in applicable business area (i.e., UM, CM, Medical Review or quality programs)

• Bachelor’s degree or advanced degree preferred.

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Hiring Preferences

• Experience with HEDIS Clinical measures data extraction strongly preferred.

• Previous experience with clinical quality improvement preferred.

Salary Range

$68,200.00 - $109,100.00

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.

Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two:

Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming

Much more than a paycheck

The total value of working at Blue Cross NC goes far beyond your paycheck. We offer benefits and perks (https://careers.bluecrossnc.com/global/en/benefits) that help you thrive, such as competitive health benefits, bonus plans based on performance, 401(k) with employer match, paid time off (plus two well-being days), and a variety of career development and wellness programs.