Clinical Quality Assurance Auditor (Chattanooga or Nashville)

BlueCross BlueShield of Tennessee is seeking a Clinical Quality Assurance Auditor to support compliance standards, optimize Star measure outcomes, and enhance the overall quality of member care within the Supplemental Data Collection team.

About the role

In this position, you will perform quality, compliance, and inter-reviewer audits to identify opportunities for improvement and ensure consistency, accuracy, and adherence to regulatory requirements. Responsibilities include reviewing and abstracting medical records, analyzing clinical data, and collaborating with internal stakeholders to support quality initiatives that positively impact Star ratings and member outcomes. The role involves educating and influencing others to improve audit quality and compliance through effective communication, feedback, and presentations.

Responsibilities

• Present and communicate audit results to appropriate parties; participate in developing procedures and standards that support and enhance quality-of-care goals across all lines of business.
• Schedule and perform routine facility, practitioner site, and medical record reviews using established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.
• Identify and evaluate areas of exposure, potential problems, and liabilities; analyze clinical data to improve individual provider compliance through education.
• Provide oversight for regional contract staff and coordinate the 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.
• Provide required documents and consulting support for quality and compliance audits.

Requirements

• 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.
• Demonstrated presentation and team facilitation skills.
• Proficient in Microsoft Office (Outlook, Word, Excel, and PowerPoint), with advanced Excel skills (including pivot tables) strongly preferred.
• Excellent oral and written communication skills, including public speaking and presentation abilities.
• Strong time and project management skills, with high attention to detail and accuracy.
• Flexibility to support provider or leadership needs outside standard business hours, including after 5:00 p.m., as required.
• Various immunizations and/or associated medical tests may be required for this position.
• Preference for candidates living in Chattanooga or Nashville to oversee occasional onsite visits to provider offices.
• Employees required to operate a BCBST-owned, personal, or rental vehicle for company business on a routine basis must maintain a valid driver’s license, auto insurance compliance with minimum liability requirements, and an acceptable motor vehicle record (MVR).

Qualifications

• Bachelor’s Degree in a healthcare-related field or equivalent work experience.