Clinical Quality and Oversight Consultant
Capital Blue Cross
full-time
Posted on:
Location Type: Remote
Location: Pennsylvania • United States
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Salary
💰 $72,870 - $137,290 per year
About the role
- Responsible for planning and executing documentation/case audits (internal and external) for assigned unit (e.g. UM, CM, delegated vendor(s))
- Responsible for educating staff on findings, and the audit tool to ensure a consistent approach to documentation and case collaboration.
- Monthly, quarterly, annually and upon request, prepares written evaluation of quality and oversight activities for assigned unit(s) to ensure regulatory/accreditation/contract compliance.
- Establishes appropriate benchmarks and analyzes reports to determine if utilization and quality performance are appropriate.
- Identify opportunities for improving processes and outcomes.
- Development and monitoring of corrective action plans and follow-up activities.
- Maintains appropriate documentation of records, reports, correspondence, training and additional quality and oversight activities to ensure comprehensive tracking of documentation that meets both regulatory and accreditation standards, including for delegation when appropriate.
- Actively engages in Capital’s compliance activities, including that of any delegated UM vendors, if applicable.
- Monitors regulatory and accreditation standards for updates and proposes updates to Policy and Procedures as required.
Requirements
- Minimum of five (5) years recent clinical experience
- Two (2) years of experience in Quality Improvement or experience with similar related activities required
- Medical management experience, including UM preferred
- Must have active current and unrestricted master’s level Behavioral Health clinical license (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure
- Certification in quality improvement preferred.
Benefits
- Medical, Dental & Vision coverage
- Retirement Plan
- Generous time off including Paid Time Off
- Holidays
- Volunteer time off
- Incentive Plan
- Tuition Reimbursement
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
documentation auditscase auditsquality improvementcorrective action plansregulatory complianceaccreditation standardsdata analysisbenchmark establishmentprocess improvementclinical experience
Soft Skills
staff educationcommunicationcollaborationanalytical thinkingproblem-solvingorganizational skillsengagementreport writingoversight activitiestraining
Certifications
master’s level Behavioral Health clinical licenseLMSWLCSWLISWLPCRegistered Nurse licensurequality improvement certification