RN- Clinical Quality Reviewer - Nurse, Senior
or drop it." So we could include a short p with location info? But location is listed in Locations list. That's substantive; we could include location in About the role or maybe separate? There's no heading for Location; we could include it in About the role paragraph. But we need to preserve all substantive information. So we need to include locations list. Could put in a
- under About the role or maybe a separate section? There's no heading for Locations; we could just include it in About the role as a list. Similarly, Pay Range info we need to include. Schedule info we need to include.
We must remove boilerplate: EEO, equal opportunity, scam-warning, cookie/navigation/legal, duplicated lines, application instructions. Also remove "Please click here for further physical requirement detail." and physical requirements maybe? It's substantive? It's about physical requirements; maybe we could include but not required heading. Could be included in About the role or maybe a separate section? There's no heading for Physical Requirements; we could embed in About the role as a note. But we might drop if considered boilerplate? It's not boilerplate; it's specific. However the instruction: "Remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions." Physical requirement is not those. So we should keep it.
Also "Our Values" etc is substantive but not under a heading; we could include in About the role or maybe a separate section? There's no heading for Values; we could embed in About the role.
We need to preserve all substantive information; do not invent or summarize away detail. So we need to keep details like mission, values, workplace model, etc.
Thus we need to craft sections:
- El Dorado Hills, CA, United States
- Long Beach, CA, United States
- Lodi, CA, United States
- Rancho Cordova, CA, United States
- Redding, CA, United States
- San Diego, CA, United States
- Woodland Hills, CA, United States
- Work with administrative staff on request of medical/clinical records.
- Analyze quality issues from both internal and external sources.
- Make recommendations for level of severity and forward to a medical director (MD).
- Prepare cases for presentation at peer review committees for group review of cases at a higher severity level.
- Prepare education letters and corrective action requests for cases in which it is deemed necessary for the provider to institute a change in their present practices, including cases in which members did not receive the necessary treatment or treatment received was potentially harmful.
- Correspond to providers regarding corrective actions reviewed.
- Collaborate with team members on cases as indicated.
- Requires an Associates Degree in Nursing.
- 5 years of prior relevant experience is required.
- Current California RN license is required.
- 5 years of case review experience required.
- Requires experience working at a health plan (managed care, government payer, or academic).
- Proven experience presenting to medical directors required.
- Excellent analytical and problem-solving skills.
- Requires deep knowledge of job area typically obtained through advanced education combined with experience.
- Viewed as a specialist within the discipline.
- May have broad knowledge of project management.
- Must have excellent interpersonal, organizational, and communication skills
About the role
... include role description, mission, values, workplace model, physical requirements, locations list maybe as
- .
But we also have separate Responsibilities and Qualifications sections.
We need to ensure we don't repeat content.
Let's extract:
From "Your Role": The Clinical Quality Review (CQR) team is responsible for reviewing potential quality of care issues (PQIs) reported by a member, a member representative, or an internal or external partner. The Clinical Quality Reviewer – Nurse, Senior will report to the Manager, Clinical Quality Review. In this role you will be responsible for understanding workflows, procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). In collaboration with our medical directors, you will follow up / report results to the appropriate committees for further resolution. You will work with a clinical team comprised of Registered Nurses (RNs), physicians and administrative staff to ensure operational compliance with timeliness and reporting requirements. You will use your clinical expertise to investigate quality of care issues related to health care concerns. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
That's the role description.
Then "About Us" includes mission, values, workplace model, physical requirements, recognition, etc.
We also have "Hybrid Virtual Work" paragraph.
We also have "Locations" list.
We also have "Pay Range for California" and "Pay Range for Bay Area".
We also have "Job Schedule: Full time".
We also have "Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day."
We also have "Our Values: Honest... Human... Courageous."
We also have "Our Workplace Model ...".
We also have "Blue Shield is a U.S. News Best Company..." etc.
We need to keep all that.
Thus About the role section could be long, but okay.
Responsibilities section: list from "Your Work In this role, you will:" bullet points.
Qualifications section: list from "Your Knowledge and Experience" bullet points.
Pay section: include the pay ranges.
Schedule section: include Hybrid Virtual Work and Workplace Model details (two days per week, etc.) plus Job Schedule: Full time.
We should not include Benefits section.
We must not include headings with empty content.
Now produce HTML.
We need to wrap content in appropriate tags:
About the role
then... maybe include
- for locations.
We must not use markdown code fences.
Let's craft.
First, About the role:
We'll combine role description, mission, values, workplace model, physical requirements, recognition, hybrid work note.
But we also have Locations list; we could put that as
- inside About the role.
We need to avoid duplication: The Hybrid Virtual Work paragraph appears also in Workplace Model; we can combine.
Let's draft:
About the role
The Clinical Quality Review (CQR) team is responsible for reviewing potential quality of care issues (PQIs) reported by a member, a member representative, or an internal or external partner. The Clinical Quality Reviewer – Nurse, Senior will report to the Manager, Clinical Quality Review. In this role you will be responsible for understanding workflows, procedures, and Blue Shield of California policies to support the technical, cultural and process changes necessary for the Medicare, Commercial and Medi-Cal lines of businesses (LOBs). In collaboration with our medical directors, you will follow up / report results to the appropriate committees for further resolution. You will work with a clinical team comprised of Registered Nurses (RNs), physicians and administrative staff to ensure operational compliance with timeliness and reporting requirements. You will use your clinical expertise to investigate quality of care issues related to health care concerns. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light.
Our Values: Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model: We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
Hybrid Virtual Work: This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Locations: