RN / Case Management / California / Permanent / Manager, Clinical Quality Review Job
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Description
Overview:
The leader in the Manager, Clinical Quality Review role manages the Blue Shield of California Promise Health Plan Clinical Quality Review (CQR) daily operations and the CQR team of nurses and coordinators. CQR investigates and reviews potential quality of care issues (PQIs) arising from member grievances and internal referrals. These reviews can result in identified opportunities for improvement for network providers which help to fulfill Blue Shield’s mission to provide care worthy of our family and friends.
Responsibilities:
*Exemplifies and models leadership behaviors to promote a Great Place to Work environment; actively seeks opportunities for self-growth and development as a leader and champions growth and development of direct reports
*Supports team with quality and productivity goals and provides appropriate coaching and feedback to ensure a high-performing team that contributes effectively to an informed end-to-end PQI review process
*Monitors PQI inventory and adjusts or helps manage workloads to back-up the team and ensure regulatory and follow-up action timeframes are met.
*Ensures compliance with all other regulatory, accreditation, legal, contractual and BSC standards; leads the department through all components of regulatory and accreditation audits and surveys
*Manages performance and hiring processes of direct reports
*Understands and identifies opportunities for process and workflow efficiencies and improvements
*Tracks operational metrics and produces regulatory and committee reports; ensures analysis of PQI and service complaint provider monitoring data and follows policy and procedure for identified outliers
*Collaborates with internal partners and leads CQR-related projects
*Provides timely and high-quality deliverables/work products
*Oversees development and updating of departmental policies and procedures
*Effectively works to solve problems and conflicts
*Ensures alignment of strategic direction for operations and designs strategies to achieve business unit goals and objectives; consults and makes recommendations to senior management/executives on significant issues.
*Operates within departmental budget
Skills
Qualifications:
*Active California RN license required; Bachelor’s or higher degree preferred
*3-5+ years hands-on clinical nursing experience across a variety of specialties required
*Quality management, risk management, peer review, or grievance review experience required
*2+ years of experience managing and leading professional staff members
*Advanced knowledge of managed care, health plan product lines (HMO, PPO, Medicare, Medi-Cal, etc.) and accreditation/regulatory agencies and state/federal regulations (DMHC, CMS, DHCS, NCQA, etc.)
*Proficient in typing skills and in use of PC-based software programs including Microsoft Word and Excel
*Excellent communication skills, both written and verbal
*Ability to coach and mentor staff and engage in difficult conversations
*Experience in cross-functional projects
*Ability to work in a fast-paced environment with fluid business situations; is flexible and adaptable
* Some information such as the email and phone number are hidden unless you are registered and logged-in
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