Remote Clinical Quality Improvement Specialist RN

Florida Blue

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United States Clinical Full-Time 32871

What is your impact?
Performs quality assessments for physicians, facility and ancillary providers considering all available information internal and external to the organization. Collaborates with internal staff and network management to define potential quality improvement activities within the corporation, at the individual or group practitioner level; facility level or network system level and could potentially involve a third party in the collaboration. Leads the full spectrum of various quality improvement initiatives to include collaboration with key stakeholders (both internal and external) for design, implementation, monitoring and relationship management.

What will you be doing?
•    Review issues related to potential quality of medical care.
•    Respond to member generated potential quality of medical care issues involving a Member/Subscriber . Help maintain compliance with the Centers for Medicare and Medicaid Services (CMS) and the Agency for Health Care Administration (AHCA) for incidents based on Statue 641.55.  Work with network representatives and/or other key stakeholders as needed to assist in resolving Quality of Care issues.  These opportunities could potentially involve internal personnel, individual or a group of physicians, a hospital or hospital system, ancillary provider or other delivery system entity and has the potential to involve a third party.
•    Perform clinical quality assessment analysis to include all available information that comes from internal and external sources to include claims and other internal data, customer inquiries, peer review findings, publicly available data, industry information and others and provide findings to key stakeholders.
•    Perform medical chart reviews to resolve Potential Quality of Care Issues.
•    Manage the relationship with all involved parties.

What is required?
4+ years related work experience. Experience Details: Health care and/or insurance industry
Related Bachelor’s degree or additional related equivalent work experience
RN – Registered Nurse – State Licensure And/Or Compact State Licensure
Strong project management experience
Experience identifying opportunities for quality improvements

What is preferred? 
Six Sigma Green Belt

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

What We Offer: 
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
•    Medical, dental, vision, life and global travel health insurance;
•    Income protection benefits: life insurance, Short- and long-term disability programs;
•    Leave programs to support personal circumstances;
•    Retirement Savings Plan includes employer contribution and employer match;
•    Paid time off, volunteer time off, and 11 holidays
•    Additional voluntary benefits available; and
•    A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.
To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $66,400 – $107,900
Typical Annualized Hiring Range: $66,400 – $83,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.