Clinical Quality Management Auditor
Blue Cross NCAbout the role
Job Description
Evaluates, analyzes and monitors staff or provider performance to achieve excellence in quality. Provides timely, relevant, accurate, and objective feedback to staff, providers, and the management team which includes a plan of action or recommendations when deficiencies are identified. Acts as technical resource and develops learning solutions that engage the learner and produces desired business goals and objectives.What You'll Do
Primarily responsible for HEDIS overreading to ensure accuracy, consistency, and compliance with quality standards
Support clinical quality leadership on planning activities and large operational activities; works with Clinical Quality leaders to define success metrics and criteria
Analyze reporting and record volumes to ensure program success and collaborate with leadership to modify/redirect activities to meet targets when necessary
Performs quality audits of member medical records to ensure compliance with HEDIS specifications
Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified
Provide timely feedback and recommendations to Clinical Quality Management Consultants based on HEDIS Audits
Drive requirements gathering for medical record abstraction tool enhancements and develop, update, and maintain desktop procedures to ensure accuracy, consistency, and compliance with organizational standards
Manage IPP STARS Care Gap requests in alignment with Blue Cross Blue Shield Association timelines and key performance indicators
Own the end‑to‑end process of initiating, tracking, and resolving support tickets, coordinating tool enhancements, and validating updates through testing in collaboration with vendors and stakeholders
May also support ongoing administration of larger and/or more complex programs
Coach newer HEDIS overreaders and assist with supplemental ad hoc HEDIS or ad hoc requests, as assigned
What You'll Bring
- RN with 3 years of clinical experience or LPN with 5 years of clinical experience required
- Must have previous work experience in applicable business area (i.e. HEDIS, Medical Record Review or quality programs)
- Bachelor's degree or advanced degree preferred
Bonus Points
Knowledge of clinical quality improvement operations, including HEDIS, Medical quality ratings, strongly preferred
Strong analytical, organization, and problem-solving skills
Strong written, and verbal communication skills and ability to successfully interact with all levels of management
Knowledge of Blue Cross NC or prior healthcare payer experience strongly preferred
Experience in conducting patient chart reviews to obtain clinical measures is preferred
What You’ll Get
The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community
Work-life balance, flexibility, and the autonomy to do great work
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental leave and support plus adoption and surrogacy assistance
Career development programs and tuition reimbursement for continued education
401k match including an annual company contribution
Salary Range
At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our s
Apply for this role
Generate a tailored application kit with a matched cover letter, interview prep, and CV highlights — in under 60 seconds.
Apply Now →Generate Application KitFree account required — sign up in 30s