Health Care

applicant

BlueCross and BlueShield of TennesseeChattanooga, TNThe purpose of this position is to support the Government Medicaid Administration division to ensure that compliance with applicable state and federal laws and regulations, as well as applicable accrediting and regulatory review agencies including, but not limited to, CMS; NCQA, the Tennessee Department of Commerce and Insurance (TDCI), Health Insurance Portability and Accountability Act of 1996 (HIPAA), and BCBST requirements and policies, as applicable.  This position is charged with developing clinical audit/evaluations to ensure appropriate protocols are followed with emphasis on quality and process improvement to better facilitate positive patient outcomes, as well as identification of barriers and formulation of recommendations to ease administrative encumbrances for providers.  The performance improvement analyst also serves as a resource for entry-level staff and as team leaders for department initiatives. Functions:• Maintain extensive knowledge of regulatory and applicable accrediting body requirements becoming a Compliance resource across the Government Medicaid Administration division and other divisions. • Develop, coordinate, and perform quality audit processes. • Serve as an educational resource and oversee preparation and implementation of studies and initiatives, surveys, and audits as well as coordinate projects, and policy development within the Government Medicaid Administration division.  • Act as a liaison to the corporate Quality Management department. • Acts as a resource in the development of programs and policies and procedures that support and enhance the overall QI program or departmental efficiencies. • Use research experience and data analytical skills to identify existing potential healthcare and service opportunities for improvement and design solutions for identified problems. • Ensure that all projects and departmental activities meet applicable regulatory and/or accrediting requirements. • Establish and maintain excellent working relationships throughout the corporation to support department, division and VSHP corporate goals and objectives. • Function as a preceptor for new staff, as well as team leader for assigned initiatives, accomplishing department goals through natural workgroup leadership and coordination. • Lead or coordinate workgroups any other meetings required to document complex standards compliance. • Organize and prioritize multiple tasks and deadlines; work independently with limited supervision and complete various projects thoroughly, accurately and timely as assigned by management. • Lead multi-disciplinary groups to identify barriers and recommendations for continuous improvements in SGMM processes.Qualifications:• Registered Nurse 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; or master's level Social Worker with active license in the state of Tennessee (LCSW, LMSW, or LAPSW). • At least two years of Medical Management Utilization Management Case Management, and Disease Management experience preferred. • Strong analytical skills • Managed care experience, or experience with regulatory or accrediting body requirements (i.e., NCQA, URAC, EQRO, CMS) and Clinical Quality Improvement experience required. • Certification as a Professional in Healthcare Quality, HIAA, or equivalent certification required, or must be obtained within one year after becoming eligible. • Excellent computer skills with direct experience in MS Office, Word, PowerPoint, and Excel required. • Facets experience preferred • Excellent interpersonal skills • Team player attitude • Excellent written and oral communication skills • Ability to manage multiple projects and priorities.Please apply via our career site at:https://www.bcbst.com/about/careers/openings/