Quality Management Nurse

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Southfield, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="https://s3.amazonaws.com/data.vizirecruiter.com/Images/BCBSMCareers+-+Quick+Reference+Guide.pdf" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="https://ejko.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_3/requisitions" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: position summary,teamwork,management,quality assurance,operations,compliance,leadership,knowledge,analysis,quality assurance,skills,degree,experience

Full-Time

Competitive Total Compensation Package

Overview: Responsible for the completion of assignments for the coordination of the BCN Quality Management Program through problem identification, development and coordination of QM studies, investigation of quality-related member and practitioner inquiries, and plan compliance with state and federal regulations and accrediting bodies. Measures and analyzes results of QI activities, recommend interventions, and conducts follow-up.
Responsibilities: <ul> <li>Coordinates the Quality Management Program through problem identification, development and coordination of QM studies and activities, including HEDIS, measurement and analysis of results, and recommendation of solutions.</li> <li>Assists leadership in the evaluation of these results contributing to the Quality Management Program Evaluation.</li> <li>Collaborates with Care Management, Customer Services, Provider Affairs and other departments to provide rapid and thorough identification, investigation and resolution of member, practitioner and provider quality related issues.</li> <li>Works with Associate Medical Director, Quality Management on development and revision of Clinical Practice Guidelines.</li> <li>Assists management with the revision of Quality Management policies related to NCQA standards.</li> <li>Develops, maintains and enhances reporting methods to identify trends in physician and member behavior.</li> <li>Completes applicable physician summaries (ex. Physician complaint Analysis, Physician Quality Profiles) as required for re-credentialing.</li> <li>Develops recommendations/tools, as indicated, to improve behavior (for example, Corrective Action Plans) Identifies potential and recurring problems that affect members and providers for the purpose of developing more effective practitioner and member education regarding BCN policies, procedures and clinical practice guidelines.</li> <li>Creates member and practitioner educational publications related to quality management activities and program information.</li> <li>Assists with health promotion activities including health fairs and wellness worksite events interacting appropriately with Health Education, Disease Management and other areas.</li> <li>Encourages teamwork to assist with employee engagement.</li> <li>Serves as Quality Management and BCN representative on internal and external committees to aid in the development and evaluation of health promotional and quality management initiatives.</li> <li>Confidentiality is maintained in all aspects of departmental operations involving physicians, providers, members and external entities.</li> <li>Assists in activities related to BCN commitment to state and federal regulations, purchaser expectations, as well as accreditation bodies such as NCQA and OFIS.</li> </ul>
Requirements: <ul> <li>Bachelor's degree in Nursing, or health-related discipline required.</li> <li>Registered nurse with a current unrestricted Michigan license required.</li> <li>Five (5) years broad clinical experience required.</li> <li>One (1) year Quality Management experience required.</li> <li> <div>Excellent organizational skills including the ability to handle multiple projects and timelines with minimal supervision required.</div> </li> <li> <div>Excellent verbal and written communication skills required.</div> </li> <li> <div>Excellent analytical skills including the ability to provide accurate, objective analysis and reporting of data required.</div> </li> <li> <div>Ability to identify, assess and resolve highly complex problems relating to the delivery of medical services to members and the provider community required.</div> </li> <li> <div>Self-directed with demonstrated ability to initiate, implement and complete projects effectively required.</div> </li> <li> <div>Basic knowledge of Microsoft Word required.</div> </li> <li> <div>Basic knowledge of Microsoft Excel and Access, or a similar software program preferred.</div> </li> <li> <div>Knowledge of statistical analysis and software preferred.</div> </li> <li> <div>Knowledge of Visual Cactus preferred.</div> </li> <li> <div>Detailed knowledge of HMO and BCN policies and procedures as they pertain to managed care, including the organization of the provider network and the roles and responsibilities of the Provider Services, Medical Management, Disease Management, and Customer Services departments preferred.</div> </li> </ul> <div id="gtx-trans" style="position: absolute; left: -121px; top: 26px;">&nbsp;</div>