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

Performs quality audits of staff/providers to ensure compliance with departmental, Plans and regulates policies and procedures. Assists in designing effective learning solutions based on analysis of quality audit results and when quality deficiencies are identified. Monitors and reports on individual and department results to include benchmarking and trending.
Acts as a day-to-day resource for technical assistance and clinical decision making. Provides guidance with interpretation of clinical aspects of Corporate Medical Policy and other clinical guidelines to assist in making medical decisions. Aligns clinical decision-making processes with regulatory requirements (e.g. DOI/ERISA/NCQA). Keeps abreast of medical knowledge, care patterns, regulatory and governmental rules and regulations.
Works with management team to support decisions on workflow process, quality improvement, goal setting and data driven information-based decision-making. Provides timely feedback to management on staff/provider performance. Acts to facilitate change efforts and promote department, division and corporate goals.

What You Have

RN with 3 years of clinical experience or LPN with 5 years of clinical experience required.
For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
Must have previous work experience in applicable business area (i.e. UM, CM, Medical Review or quality programs).
Bachelor's degree or advanced degree preferred.

Bonus Points

Experience presenting to clinical staff in primary care settings
Knowledge of HEDIS or healthcare quality measures
Strong Excel and PowerPoint proficiency
Ability to translate data into insights (data storytelling)
Strong presentation and communication skills
Relationship-building with provider systems
Flexibility and willingness to travel (25%)

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
Learn more

Where You’ll Work

Our Hybrid Flex approach is built on presence with a purpose – giving you flexibility to work remotely with intentional in-person connection – that supports a workplace that’s flexible, connected, and future focused.

In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter.

Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$73,698.00 – $117,917.00

Skills

Clinical Decision Support (CDS), Clinical Quality Management, Clinical Research, Health Care, Healthcare Operations, Healthcare Policies, Health Information Technology (HIT), Medical Knowledge, Patient Safety, Quality Improvement

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