Quality Management RN
Blue Cross Blue Shield of Michigan

Responsible for maintaining NCQA accreditation for the Enterprise, focusing primarily on ensuring compliance and demonstrating our commitment to delivering high-quality care for all members.

• Create, manage and monitor NCQA documentation.
• Develop, coordinate, monitor and maintain documented evidence of NCQA compliance.
• Responsible for educating staff across the organization on NCQA standards and requirements.
• Responsible for evaluating current practices and identifying gaps in compliance and for identifying opportunities for improvement and taking necessary action.
• Identify key stakeholders to coordinate compliance activities.
• Identify potential problems that may have an adverse impact on accreditation and escalate to leadership to mitigate and resolve.
• Responsible for leading weekly meetings to create, review, update, or provide recommendations for supporting documents.
• Manage and continually monitor assigned NCQA standards/elements/factors simultaneously.
• Establish project plans to ensure NCQA compliance.
• Conduct file reviews to evaluate the compliance with defined criteria, which includes the selection of files using systematic sampling, conducting file reviews based on specified criteria, identifying compliance gaps, developing report cards to communicate gaps, recommending solutions to close gaps, working collaboratively with operational areas to implement corrective action plans as necessary and monitor the corrective action plan progress.
• Lead meetings to inform the operational areas of their file review outcomes.
• Responsible for conducting data analysis and reporting, this includes literature searches, defining and submitting data requirements, collecting data, conducting quantitative and qualitative analysis, interpreting the data, identifying trends, identifying barriers, formulating recommendations, identifying key stakeholders to coordinate activities based on recommendations, implementing and monitoring interventions to mitigate barriers, developing reports, papers and/or other materials in a clear and concise manner and reporting outcomes to leadership and various committees.
• Responsible for responding to inquiries related to assigned NCQA standards for both internal and external customers, this includes investigating the substance of inquiries, interpreting the associated standards, formulating a response consistent with the standard, and seeking leadership approval prior to responding.
• Responsible for communicating monthly policy updates and process changes to the appropriate operational areas.
• Responsible for communicating key findings and recommendations to various committees and audiences, developing reports, papers and/or other materials in a clear and concise manner.

"Qualifications"

• Bachelor's degree in nursing, allied health, risk management or other health care related field preferred.
• Four years of acute patient care with broad clinical background required.
• Three years of quality management/performance improvement or related experience with at least one year of audit/reporting experience preferred.
• Current, active and unrestricted Michigan Registered Nurse license required
• CPHQ certification preferred
• Excellent analytical and problem-solving skills.
• Organizational skills and ability to prioritize; must be able to lead multiple activities with varying timelines and able to work independently.
• Excellent verbal, written communication and interpersonal skills.
• Knowledge of managed care philosophy, policies, and procedures.
• Knowledge of outcomes management, quality reporting components, CQI quality management principles and program, accreditation and regulatory processes, such as National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS) and Michigan Department of Health and Human Services (MDHHS).
• Knowledge of reimbursement policies.
• Knowledge of project management principles.
• Knowledge of ICD-10 and CPT coding and the Enterprise benefits and program requirements.
• Proficient in Microsoft Office Suites.
• Ability to develop and maintain effective working relationships internally and externally.

Department summary / Preferences:

Great organizational skills, able to multitask, work well in a fluid environment, insurance knowledge.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

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