10 days old

RN - Quality Management

BCBSM
Southfield, MI 48076
  • Job Code
    BCB005PJ
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, recommends interventions and conducts follow-up.


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. Assists leadership in the evaluation of these results contributing to the Quality Management Program Evaluation. 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. Works with Associate Medical Director, Quality Management on development and revision of Clinical Practice Guidelines. Assists management with the revision of Quality Management policies related to NCQA standards. Develops, maintains and enhances reporting methods to identify trends in physician and member behavior. Completes applicable physician summaries (ex. Physician complaint Analysis, Physician Quality Profiles) as required for re-credentialing. 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.Creates member and practitioner educational publications related to quality management activities and program information.
Assists with health promotion activities including health fairs and wellness worksite events interacting appropriately with Health Education, Disease Management and other areas. Encourages teamwork to assist with employee engagement. 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. Confidentiality is maintained in all aspects of departmental operations involving physicians, providers, members and external entities.
Assists in activities related to BCN commitment to state and federal regulations, purchaser expectations, as well as accreditation bodies such as NCQA and OFIS.


  • Bachelor's degree in Nursing, or health-related discipline required.

  • Registered nurse with a current unrestricted Michigan license required.

  • Five (5) years broad clinical experience required.

  • One (1) year Quality Management experience required.

  • Excellent organizational skills including the ability to handle multiple projects and timelines with minimal supervision required.

  • Excellent verbal and written communication skills required.

  • Excellent analytical skills including the ability to provide accurate, objective analysis and reporting of data required.

  • Ability to identify, assess and resolve highly complex problems relating to the delivery of medical services to members and the provider community required.

  • Self-directed with demonstrated ability to initiate, implement and complete projects effectively required.

  • Basic knowledge of Microsoft Word required.

  • Basic knowledge of Microsoft Excel and Access, or a similar software program preferred.

  • Knowledge of statistical analysis and software preferred.

  • Knowledge of Visual Cactus preferred.

  • 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.
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.





Posted: 2020-06-30 Expires: 2020-07-29
Sponsored by:
ADP Logo
Sponsored by:
Bank of America Logo

Featured Jobs[ View All ]

Featured Employers

Before you go...

Our free job seeker tools include alerts for new jobs, saving your favorites, optimized job matching, and more! Just enter your email below.

Share this job:

RN - Quality Management

BCBSM
Southfield, MI 48076

Join us to start saving your Favorite Jobs!

Sign In Create Account
Powered ByCareerCast