Clinical Quality Assurance Auditor - Knoxville

We are seeking an auditor based in the Knoxville, TN region to join our Clinical Quality Assurance team. Our RN auditors perform reviews for network providers to ensure members receive quality care in offices that adhere to our internal quality standards as well as regulatory requirements from Medicare, TennCare, and NCQA.

About the role

While working from home, the auditor will travel to provider offices in the Knoxville region to perform various review types for all lines of business. Flexibility is required, as provider or leadership needs may occasionally require support outside standard business hours, including after 5:00 p.m. Various immunizations and/or associated medical tests may be required for this position.

Responsibilities

• Present and communicate audit results to appropriate parties; participate 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 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 with 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.
• Reside in the Knoxville regional area of TN to facilitate onsite visits to provider offices.
• 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).
• Excellent oral and written communication skills.
• Excellent time and project management skills.

Qualifications

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

Employees who are required to operate either a BCBST-owned vehicle or a personal/rental vehicle for company business on a routine basis will be automatically enrolled in the BCBST Driver Safety Program. This includes maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements, and maintaining an acceptable motor vehicle record (MVR).