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The Supplemental Data Collection team at BCBST is seeking a Clinical Quality Assurance Auditor to support the organization in meeting compliance standards, optimize Star measure outcomes, and enhance the overall quality of member care.
In this role, you will perform quality, compliance, and inter-reviewer audits to identify opportunities for improvement and ensure consistency, accuracy, and adherence to regulatory requirements. You will review and abstract medical records, analyze clinical data, and collaborate with internal stakeholders to support quality initiatives that positively impact Star ratings and member outcomes. Through effective communication, education, and feedback, you will help drive clinical excellence and promote proper quality of care across the Supplemental Data Collection (SDC) project.
To be successful in this role, in addition to the core job requirements, you'll bring strong critical thinking skills, nursing leadership experience, and the ability to analyze and interpret clinical data. Excellent communication, public speaking, and presentation skills are essential, as this role requires educating and influencing others to improve audit quality and compliance outcomes. Advanced proficiency in Excel, including pivot tables, as well as experience with Word, PowerPoint, and Teams, is strongly preferred. A high level of attention to detail, accuracy, and the ability to adapt to changing provider and business needs are critical for success.
You will be a strong candidate for this role if you have the following:

• Registered Nurse (RN) with an active Tennessee license or a license from a Nurse Licensure Compact state.
• 4 years of healthcare experience.
• 1 year of managed care experience or experience with Quality Medical Record Review.
• Experience with HEDIS and/or STARS data collection.
• Strong analytical skills with the ability to identify trends and recommend process improvements.
• We foster a culture where innovation is encouraged, supporting employees with the tools and resources needed to succeed while promoting growth, creativity, and continuous learning.
• Preference for candidates living in Chattanooga or Nashville to oversee occasional onsite visits to provider offices.

Note:

• Flexibility is required, as provider or leadership needs may occasionally require support outside standard business hours, including after 5:00 p.m

Job Responsibilities

• Presenting and communicating audit results to appropriate parties; participates in the development of procedures and standards that support and enhance all lines of business' quality of care goals.
• Schedule and perform routine facility, practitioner site, and medical record reviews, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.
• Identifying and evaluating areas of exposure, potential problems and liabilities. Analyze clinical data to improve individual provider compliance with education; provide oversight for regional contract staff and coordinate the effort of retrieval of HEDIS and/or STARS records; complete medical record audits for HEDIS and/or STARS data collection or quality of care reviews as required.
• Providing required documents and consulting support for quality and compliance audits.
• Various immunizations and/or associated medical tests may be required for this position.

Job Qualifications
Education

• Bachelor's Degree in Health Care related field or equivalent work experience.

Experience

• 4 years - Health Care experience required.
• 1 year - Managed care experience or experience with Quality Medical Record Review.

Skills/Certifications

• Demonstrated presentation and team facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Excellent oral and written communication skills
• Excellent time and project management skills
• Strong analytical, planning, organizational and research skills

License

• Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver's license, auto insurance compliance with minimum liability requirements; as defined in the "Use of Non BCBST-Owned Vehicle" Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). *The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.
Number of Openings Available
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
Applying for this job indicates your acknowledgement and understanding of the following statements:
BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.
Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:
BCBST's EEO Policies/Notices
BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.