Health Plan Quality Assurance Specialist - RN

At Blue Cross and Blue Shield of Minnesota, we are committed to paving the way for everyone to achieve their healthiest life. We are looking for dedicated and motivated individuals who share our vision of transforming healthcare. As a Blue Cross associate, you are joining a culture that is built on values of succeeding together, finding a better way, and doing the right thing. If you are ready to make a difference, join us.

This position is accountable for performing a wide variety of services related to quality investigations. The associate works as a member of the care management clinical audit team to ensure compliant, effective and efficient investigations of quality issues impacting the health and service of Blue Cross and Blue Plus members. This work contributes directly to adherence with regulatory and accreditation requirements including the organizations Quality Improvement Program. This position collaborates with multiple stakeholders at many levels across the company, as well as with external entities, providing coordination and support as required.

Perform the initial triage and review of quality issues referred to the Quality Improvement Department, including confirmation of clinical issue needing investigation and categorization for tracking. Perform Quality of Care and Quality of Service reviews which includes summarizing medical records and determining if complaint is substantiated. Draft questions for practitioners and clinic staff to answer related to the investigation. Organize and manage documentation, policies and procedures, job aids, manuals, file system, reporting and outcome measurement related to the quality investigations, including connections with other departments (contracting, credentialing, medical management, etc.). Draft and implement corrective action plans for providers and practitioners when needed, including tracking and follow-up (case audits, etc.). Develop and manage regular standardized reporting to meet regulatory, accreditation, contractual and other requirements; including spreadsheets, databases and other systems as needed; including summarizing cases and analysis; creating presentations and facilitating Director-Level Quality Committee reports. Ensure compliance with regulatory and accreditation standards, including HIPAA, NCQA and Department of Labor regulations. Ad Hoc collaboration with MDH internal stakeholders during external audits. Special projects as assigned.