RN / Case Management / California / Permanent / Manager, Clinical Quality Review Job
Company: Blue Shield of California
Location: Glendale
Posted on: January 27, 2023
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Job Description:
Overview: The leader in the Manager, Clinical Quality Review
role manages the Blue Shield of California Promise Health Plan
Clinical Quality Review (CQR) daily operations and the CQR team of
nurses and coordinators. CQR investigates and reviews potential
quality of care issues (PQIs) arising from member grievances and
internal referrals. These reviews can result in identified
opportunities for improvement for network providers which help to
fulfill Blue Shields mission to provide care worthy of our family
and friends. Responsibilities:*Exemplifies and models leadership
behaviors to promote a Great Place to Work environment; actively
seeks opportunities for self-growth and development as a leader and
champions growth and development of direct reports*Supports team
with quality and productivity goals and provides appropriate
coaching and feedback to ensure a high-performing team that
contributes effectively to an informed end-to-end PQI review
process*Monitors PQI inventory and adjusts or helps manage
workloads to back-up the team and ensure regulatory and follow-up
action timeframes are met.*Ensures compliance with all other
regulatory, accreditation, legal, contractual and BSC standards;
leads the department through all components of regulatory and
accreditation audits and surveys *Manages performance and hiring
processes of direct reports*Understands and identifies
opportunities for process and workflow efficiencies and
improvements*Tracks operational metrics and produces regulatory and
committee reports; ensures analysis of PQI and service complaint
provider monitoring data and follows policy and procedure for
identified outliers*Collaborates with internal partners and leads
CQR-related projects*Provides timely and high-quality
deliverables/work products*Oversees development and updating of
departmental policies and procedures*Effectively works to solve
problems and conflicts*Ensures alignment of strategic direction for
operations and designs strategies to achieve business unit goals
and objectives; consults and makes recommendations to senior
management/executives on significant issues.*Operates within
departmental budget
Keywords: Blue Shield of California, Glendale , RN / Case Management / California / Permanent / Manager, Clinical Quality Review Job, Executive , Glendale, Arizona
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