Clinical Quality Assurance Auditor - Knoxville

The Clinical Quality Assurance team is looking for an auditor based in the Knoxville, TN region.Our RN auditors perform reviews for network providers to ensure our members are receiving quality care in offices that adhere to our internal quality standards as well as those requirements from regulatory bodies such as Medicare, TennCare and NCQA.While working from home, the auditor will travel to provider offices in the Knoxville region to perform different review types for all lines of business.

• 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.
• We foster a culture where innovation is encouraged, supporting employees with the tools and resources needed to succeed while promoting growth, creativity, and continuous learning.
• Candidate should reside in the Knoxville regional area of TN to facilitate onsite visits to provider offices.

• Flexibility is required, as provider or leadership needs may occasionally require support outside standard business hours, including after 5:00 p.m

• →Presenting and communicating audit results to appropriate parties; participates 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, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements. 
• →Identifying and evaluating 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 effort of 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.
• →Providing required documents and consulting support for quality and compliance audits.
• →Various immunizations and/or associated medical tests may be required for this position.

Education

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

Experience

• 4 years - Health Care experience required.
• 1 year - Managed care experience or experience with Quality Medical Record Review.

Skills\Certifications

• 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
• Strong analytical, planning, organizational and research skills

License

• Registered Nurse (RN) 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.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices