BlueCross BlueShield of Tennessee Clinical Consultant in Chattanooga, Tennessee

The Clinical Consultant, HEDIS Clinical Improvements, will manage and coordinate population based clinical quality improvement studies, projects, and workgroups designed to achieve best possible HEDIS and disease management outcomes and to maintain these.

The person in this position is accountable for actionable studies and initiatives which will guide clinical quality improvement and which will advance company objectives, contract requirements, and member’s health outcomes in accordance with accreditation body standards (NCQA and URAC), state and federal rules and regulations. This position will also strive to design, coordinate and lead initiatives which improve the quality of health care services delivered by network providers in accordance with “best practice standards”. This position will interface and collaborate with Medical Directors, Quality Management, Medical Informatics, Network Services, and the management of these areas and customer service areas.

Job Description:

Job Duties & Responsibilities

Effective 7/22/13: This Position requires an 18 month commitment before posting for other internal positions.

  • Manage clinical quality improvement studies, activities and projects
  • Assist and support service quality improvement studies, activities and projects
  • Coordinate the activities of multiple departments in support of clinical quality improvement studies / activities
  • Collaborate with other departments to continuously improve HEDIS outcomes
  • Conduct literature research to guide and support clinical quality improvement studies / activities
  • Develop oral and written presentations with supporting materials related to above
  • Coordinate and facilitate clinical quality improvement workgroups / project teams
  • Develop and write reports of clinical quality improvement studies / activities including executive level summaries with analyses with conclusions
  • Produce visual explanations and conduct research studies related to the above-mentioned activities
  • Assess effectiveness of and create and/or disband/combine clinically focused workgroups as appropriate to support the overall priorities and strategies for HEDIS and health outcomes Develop and maintain relationships with and consistently work with medical directors, senior and executive management
  • Exercise a high degree of independent judgment in identifying potential vulnerabilities and opportunities for improvement and promptly lead teams toward documentation and implementation of solutions
  • Participate in the development and implementation of new clinical projects to support continuous quality improvement Maintain knowledge of NCQA URAC and Federal regulations (TennCare Standard Operating Procedures and CMS Rules and Regulations) as well as corporate and departmental guidelines affecting the clinical quality improvement process
  • Effectively perform all other duties assigned

Job Qualifications

Education

  • Bachelor’s Degree in Nursing with active RN 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; or a Bachelor’s Degree in Public Health, Community Health, Epidemiology, Medical Informatics or health-related field required

Experience

  • At least three years clinical experience or prior experience in public health or community health / outreach required
  • At least three years in managed care, health insurance industry, or quality improvement environment highly desired
  • Prior experience in data / analytics or conducting research and analysis of various activities including making recommendations to support the objectives of the activity highly desired
  • Experience and demonstrated effectiveness in project management, coordination of multidisciplinary teams highly desired

Skills/Certifications

  • Familiarity with quality / research study design
  • Competency in computer skills, word processing, spreadsheet and database management
  • Strong verbal and written communication skills
  • Ability to work independently and as part of a team

Position Specific Requirements - BlueCare General Summary

  • The Clinical Consultant, HEDIS Clinical Improvements, will manage and coordinate population based clinical quality improvement studies, projects, and workgroups designed to achieve best possible HEDIS and disease management outcomes and to maintain these.
  • The person in this position is accountable for actionable studies and initiatives which will guide clinical quality improvement for TennCare, DSNP and Cover Tennessee lines of business and which will advance company objectives, contract requirements, and member’s health outcomes in accordance with accreditation body standards (EQRO, NCQA and URAC) and CMS.
  • This position will also strive to design, coordinate and lead initiatives which improve the quality of health care services delivered by network providers in accordance with “best practice standards”.
  • This position will interface and collaborate with Medical Directors, Quality Management, Medical Informatics and HEDIS Analytics,, Network Services, and the management of these areas and customer service areas.

Duties

  • Assess effectiveness of and create and/or disband/combine clinically focused workgroups as appropriate to support the overall priorities and strategies for HEDIS and health outcomes for BlueCare Tennessee.
  • Participate in the development and implementation of new clinical projects to support continuous quality improvement in TennCare, DSNP and Cover Tennessee lines of business.
  • Maintain knowledge of NCQA, EQRO, TennCare and CMS Rules and Regulations, TennCare DSNP, URAC Cover Tennessee contracts and Federal regulations as well as corporate and departmental guidelines affecting the clinical quality improvement process

Job Specific Requirements:

Number of Openings Available:

1

Worker Type:

Employee

Worker Sub-Type:

Regular

Company:

VSHP Volunteer State Health Plan, Inc

BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to 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 membership in a historically under-represented group.

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotineand/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.

About Us

As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health for over 65 years. More than that, we're your neighbors and friends – fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.